Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2790) you received on May 26, 2021.
You asked the Plan to pay for the crown. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested service is not among those covered under this benefit. The Plan covers only those dental codes listed in the Optional Supplemental Schedule of Benefits. Dental code D2790 is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the crown (D2790) you received on May 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for surgical services (27447) provided on May 18, 2021.
You asked the Plan to waive the coinsurance for surgical services. You say that the services should be covered as you spent the night in the hospital. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a 20% coinsurance for surgical services. (The allowed amount is $13,178.86, 20% of that is $2,6,35.77). The record shows there was no written order from the provider to have you admitted as inpatient. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for surgical services (27447) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on April 29, 2021.
You asked the Plan to pay for the unspecified preventative procedure. You say that you were told this was an in-network provider and expected these services to be covered. The Plan denied your request. The Plan says they have agreed to partly overturn this claim and process the comprehensive oral exam and panoramic x-ray as in-network services. This is a one-time exception that is being made due to a miscommunication about the network status of the provider. However, the unspecified preventative procedure (personal protective equipment for COVID-19) is not covered by the Plan regardless of the network status of the provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventative procedure (D1999) provided on April 29, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on April 5, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular genetic risk assessment panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. We looked at the file and the rules. The medical records provided do not clearly document that the results of the testing would be used in the management of a specific medical problem. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on April 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 27, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this copayment. You said that this should be covered in full because it was related to COVID-19 (the Coronavirus). The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment per trip for ambulance services. 

You have been asked to pay a $395 copayment per trip for the ambulance services. There is no provision in your contract for a waiver of this amount, even if related to COVID-19. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on April 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and full cast high noble metal crown (D2790) provided on April 1, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied your request. The Plan says out-of-network dental care is not covered. The provider in this case is not part of the Plan's dental network.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover dental care when the services are received from out-of-network providers.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the provider in this case is not part of the Plan's network. Therefore, we decided that the Plan does not have to pay for the intraoral periapical x-ray (D0220) and full cast high noble metal crown (D2790) provided on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 8, 2021, to July 9, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that this was an emergency so it should be covered in full. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $298 copayment per day for days 1-7 for inpatient hospital services. Records show that you were in the hospital for one day. You were charged a one-day copayment of $298. This copayment applies regardless of the reason for the hospital services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 8, 2021, to July 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on June 22, 2021.
You asked the Plan to waive the copayment for cataract surgery. You say that you purchased insurance to help with medical bills, but feel you are being charged more than original Medicare. The Plan denied your request. The Plan says the copayment applied was correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center setting.
You have been asked to pay $254.61 for a cataract surgery, which is less than your $290 copayment. Cataract surgery falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for cataract surgery provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 25, 2021, to June 29, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for days 1-5 for inpatient hospital care. You received inpatient hospital care from June 25, 2021, to June 29, 2021. Therefore, you are responsible to pay a $300 copayment for days 1-4 (June 25, 2021, June 28, 2021). However, you are only being asked to pay
$900, which is less than the total copayment amount. You have been asked to pay a $300 copayment for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 25, 2021, to June 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on May 29, 2021.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says you are covered for up to 100 days each benefit period for inpatient services in a skilled nursing facility (SNF). The Plan also says that the benefit period has been exceeded.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from September 11, 2020, to May 28, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on May 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81439, 81408, 81407, and 81291) provided on March 25, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (81439, 81408, 81407, and 81291) provided on March 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve the out-of-network physical therapy services. You say that this out-ofnetwork
provider is the only one that has the machines you need. The Plan denied your request. The Plan says
there are providers available in-network who can provide physical therapy services for you. The Plan has
provided alternatives to you.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for the general health panel provided on April 20, 2021, by a network provider.
You asked the Plan to hold you harmless for the general health panel. You say that you do not feel that you should be required to pay this amount and that the Plan should make the provider remove this charge from your account. The Plan denied your request. The Plan says that payment for this service was correctly denied as this cannot be covered by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the general health panel by a contract provider. The file does not show that the Plan provided notice that the general health panel would not be covered. Under Medicare rules, this means the general health panel is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the general health panel provided on April 20, 2021, by a network provider.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation services rendered on April 28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code 99417 (prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the evaluation services rendered on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Durable Medical Equipment (V2632) and Medicare Part B Drugs (J0171, J2250, J3370) provided on June 29, 2021.
You asked the Plan to waive the coinsurance for DME and Medicare Part B Drugs. You say that the services should be covered in full. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable medical equipment (DME) and Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for DME and related supplies (The allowed amount is $293.48, 20% of that equals $58.70) and Medicare Part B Drugs (The total allowed amount is $39, 20% of that equals $7.80) for a total cost sharing of $66.47. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Durable Medical Equipment (V2632) and Medicare Part B Drugs (J0171, J2250, J3370) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on June 15, 2021.
You asked the Plan to pay for the dental items. You say that the dentures you had done in 2019 were no good even after having them adjusted multiple times. You say that you needed new dentures. You also say that you had been wearing your dentures that were 30 years old and worn down. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are listed as covered, the frequency limit has been exceeded. the record shows that the Plan paid for dentures that you received on May 9, 2019. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower denture (D5120) provided on June 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the Plan states you request does not meet Medicare guidelines because the enrollee is receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF). The Plan states all the services they need are offered at the IRF. The Plan states transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 20, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the benefit of a $300 allowance was applied to the purchase.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan applied the eyewear benefit allowance of $300 to your purchase and you are responsible to pay the difference. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic cardiovascular risk assessment testing provided on April 27, 2021.
You asked the Plan to pay for the genetic cardiovascular risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the genetic cardiovascular risk assessment testing provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on June 15, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the
same specialty must bill and be paid as though they were a single physician.

We looked at the file and Medicare rules. The file shows that billed procedure code 99231 (subsequent hospital
care) was bundled to code 01482 (anesthesia for open procedures on bone of lower leg) billed by a physician of
the same specialty in the same group practice. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the
anesthesia services rendered on June 15, 2021.