Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Zoll Life Vest provide on August 5, 2021.
You asked the Plan to waive the coinsurance for the Zoll Life Vest. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was 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 related supplies. You have been asked to pay a 20% coinsurance for the Zoll Life Vest. This item falls within the durable medical equipment (DME) and related supplies 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 coinsurance for the Zoll Life Vest provide on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on May 22, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 47563-AS (1 Units) remains not supported.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided to the enrollee on May 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the athletic mouthguard fabrication rendered on June 24, 2021.
You asked the Plan to pay for these services. You say that you wouldn't have gone ahead with the procedure if you knew it was not covered. The Plan denied your request. The Plan says the services are not covered.
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 athletic mouthguard fabrication rendered on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a heated humidifier provided from May 13, 2021, to July 13, 2021.
You asked the Plan to waive the coinsurance for a heated humidifier. You say that you disagree with the charges because the device did not work and you returned it. 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 20% coinsurance for DME and related supplies. The medical records show that you received a heated humidifier from May 13, 2021, to July 13, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount per each date is $17.50 and 20% of that is $3.50. The total amount you owe is: $3.50 (coinsurance) x 3 (dates of service) = $10.50.
You have been asked to pay the total coinsurance amount of $10.50 for a heated humidifier. A heated humidifier falls within the DME and related supplies 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 coinsurance for a heated humidifier provided from May 13, 2021, to July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on July 6, 2021 to August 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that please find the attached medical records which establish full medical necessity for the services billed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) provided on July 6, 2021 to August 3, 2021 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an A-C IOL provided on August 2, 2021.
You asked the Plan to pay for an A-C IOL. You say that the item at issue was the best and most effective option for your situation. The Plan denied your request. The Plan says the item at issue is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an A-C IOL provided on August 2, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service provided on June 25, 2021.
You asked the Plan to waive the copayment for the ambulance service. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was 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 $50 copayment for ground ambulance. You have been asked to pay a $50 copayment for the ambulance service. This service falls within the ambulance 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 the ambulance service provided on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), 4 bitewing x-rays
(D0274) and a prophylaxis cleaning (D1110) provided on June 1, 2021, to June 14, 2021.
You asked the Plan to pay for a periodic oral evaluation, bitewing x-rays and a prophylaxis cleaning. You say
that you disagree with the denial. You also say that you disenrolled from the Plan, re-enrolled into the Plan, and
was told by a Plan rep that your benefit allowance would reset. The Plan denied your request. The Plan says
your service has been denied as the calendar year maximum for 2021 has been met.
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.
We looked at the file and Medicare rules. The records show that you received dental services on January 6, 2021 and the total amount paid by the Plan was $135. The records also show that you received dental services on February 17, 2021 and the total amount paid by the Plan was $1,365. Specifically, your maximum benefit allowance for the year was exhausted prior to services being rendered in June 2021 ($135 + $1,365 = $1,500). Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewing x-rays and a prophylaxis cleaning have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), 4 bitewing x-rays (D0274) and a prophylaxis cleaning (D1110) provided on June 1, 2021, to June 14, 2021.
Your complaint about a Plan representative advising your dental allowance would reset/restart since re-enrolling into the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intravenous infusions provided from July
27, 2021, to July 29, 2021.
You asked the Plan to waive the copayments for intravenous infusions. You say that the infusions were to help
you during a flair. 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 $295
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
The record shows that you received intravenous infusions from July 27, 2021, to July 29, 2021, for a total of 3 services. Therefore, you are responsible to pay the allowed amount of $193.29, which is less than the $295 copayment per each visit. The total amount you owe is: $193.29 (copayment) x 3 (intravenous infusions) = $579.87. You have been asked to pay the total copayment amount of $579.87 for intravenous infusions. Intravenous infusions fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for intravenous infusions provided from July 27, 2021, to July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on June 30, 2021.
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you disagree with the charges. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $30 copayment for each specialist visit, including telehealth visits.
You have been asked to pay a $30 copayment for the specialist telehealth visit. Specialist telehealth visits fall within the Doctor Visits 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 a specialist telehealth visit provided on June 30, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on July 31, 2021.
You asked the Plan to pay for CT scan 70450. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70450 has a procedure-to-procedure (PTP) edit of 1 with code 70496 so cannot be separately paid without an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code CT scan 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on July 31, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on June 28, 2021.
You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says the enrollee was in hospice on this date of service and the service is not covered by the Plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the oral exam, cleaning, x-rays, and filling for tooth #21 provided on May 4, 2021.

You asked the Plan to provide additional reimbursement for the dental services. You say that you believe that you have not been reimbursed the correct amount. The Plan denied your request. The Plan says an appeal decision was not made since the timeframe was missed.

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, this pays only a portion for services rendered by OON providers. The Plan applied the cost sharing to the allowable charges for these dental services. It is noted that an in-network provider must accept the allowable charges, but that OON providers may bill you for the difference between their charge and the amount paid by the Plan. Review of the claim shows that the Plan reimbursed the correct amount, assessing you 50% coinsurance based on the allowable rate for the exam, cleaning, and x-ray and 55% for the filling. Therefore, we decided that the Plan does not have to provide additional reimbursement for the oral exam, cleaning, x-rays, and filling for tooth #21 provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 10, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in a nursing facility setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 10, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 1, 2021.
You asked the Plan to pay for the ambulance service. You say that you called 911 because you thought the enrollee was having a heart attack. You say that the paramedics advised the enrollee should go to the hospital. You say that you refused transport as you knew you would not be able to stay with the enrollee. You also say that no one would take care of the enrollee at the hospital. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since there was no transport provided, there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on June 1, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 1, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on July 19, 2021, to July 22, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not feel like you should have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $492 copayment per day for days 1-4, there is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $492 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $984 ($492 x 2 days = $984). An inpatient hospital stay 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 an inpatient hospital stay provided by a participating provider on July 19, 2021, to July 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 17, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met.
Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a maxillary partial denture (D5211) provided by an out-of-network provider on August 5, 2021.
You asked the Plan to pay for a maxillary partial denture. You say that you do not agree with the amount you are being charged. The Plan denied your request. The Plan says there is a $1,500 allowance for dental services. The Plan says that the enrollee is responsible for any amount over the allowance amount.
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 covers a maxillary partial denture when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. There is a combined allowance amount of $1,500 for dental services. The benefit has been exhausted. The total amount you are being asked to pay is $1,415. Based on this
information, we decided that the maximum allowance amount has been exhausted. Therefore, we decided that the Plan does not have to pay for a maxillary partial denture (D5211) provided by an out-of-network provider on August 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on May 12, 2021.

You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 19, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 19, 2021.