Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on June 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that you went online, and it showed the provider was an in-network provider. The Plan denied your request. The Plan says the provider is an out-of-network provider. Therefore, coverage for this service was denied.  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 an office visit provided on June 30, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ursodiol capsule, 30 mg.  You asked the Plan to pre-approve Ursodiol. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ursodiol capsule, 30 mg.   Benefits for Ursodiol may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a realignment of complete maxillary denture (D5750) provided by a participating provider on June 10, 2021.  You asked the Plan to pay for a realignment of complete maxillary denture. You say that the dentures you have need to be realigned. You say that it is affecting your speech, chewing, and biting. The Plan denied your request. The Plan says the dental services that were provided are not covered benefits.  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 a realignment of complete maxillary denture (D5750) provided by a participating provider on June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on August 10, 2021.  You asked the Plan to pay for the dental service. You say that this is a covered part of your oral surgery process. You say that this should be covered. You say that a different code should have been used. You also The Plan denied your request. The Plan says fixed partial denture sectioning is not listed as a covered service.  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 fixed partial denture sectioning is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the denture reline (D5750) provided on September 14, 2021.  You asked the Plan to pay for the dental service. You say that your upper denture does not fit anymore. You also say that it has caused sores in your mouth. The Plan denied your request. The Plan says denture reline is not listed as a covered service.  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 denture reline is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the denture reline (D5750) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for extracranial study services provided on September 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for extracranial study services. You say that you are a participating provider with the Plan. The Plan denied your request. The Plan says the provider is not a network provider, and the services were not referred by a network provider.  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 extracranial study services provided on September 1, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound (76755) provided on June 16, 2021.  You asked the Plan to waive the copayment for the retroperitoneal ultrasound. You say that the services should be covered as you spoke with the Plan after having the procedure and was told there would be no copayment. The Plan denied your request. The Plan says the cost-sharing 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 $100 copayment for Outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a $47.62 copayment for a retroperitoneal ultrasound, which is less than the $100 stated in the Plan's contract. The record indicates that there was no phone call made to the plan to verify plan benefits. Retroperitoneal ultrasounds fall within the Outpatient diagnostic tests and therapeutic services and 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 copayment for a retroperitoneal ultrasound (76755) provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), gingival irrigation (D4921), and take home drugs (D9630) provided from August 30, 2021, to September 1, 2021.  You asked the Plan to pay for the dental services. You say that you were advised the services would be covered. The Plan denied your request. The Plan says the claim was processed correctly.  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 comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded.  The record shows that the Plan paid for a comprehensive oral evaluation that you received on July 25, 2020. Additionally, the gingival irrigation and take home drug are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), gingival irrigation (D4921), and take home drugs (D9630) provided from August 30, 2021, to September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible and the copayment for a surgery provided on July 27, 2021.  You asked the Plan to waive the deductible and the copayment for the surgery. You say that this was an emergency situation, and the billing code was incorrect. The Plan denied your request. The Plan says the proper deductible and copayment was applied for this service.  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 $1000 deductible and a $300 copayment for each Medicare-covered outpatient surgery at an ambulatory surgical center.   You have been asked to pay a $1000 deductible and a $300 copayment for the surgery. The surgery falls within the Outpatient surgery, including 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 deductible and the copayment for a surgery provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and pontics (D6245 x 2) provided on August 18, 2021.  You asked the Plan to pay for the dental services. You say that you feel you were misled regarding your coverage. You say that you were advised by the dentist that these services would be covered. The Plan denied your request. The Plan says the retainer crowns and pontics 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 retainer crowns and pontics are not among those covered under this benefit. Additionally, the file shows that the treatment plan indicates that this is an estimate only and coverage may be different. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and pontics (D6245 x 2) provided on August 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on September 23, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.  The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be entered on the claim when reporting pharmacogenomics testing.  We looked at the file and Medicare rules. The documentation in this case does not show that the claim was billed with the appropriate Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 1, 2020, to July 24, 2020.  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 the provider reported skilled services with the incorrect Patient Driven Payment Model (PDPM) Health Insurance Prospective Payment System (HIPPS) Score.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the available medical records do not verify a diagnosis of diabetes mellitus which required insulin injections for all 7 days, and insulin order changes on two or more days. The documentation does not support that IV fluids were administered to treat a diagnosis of dehydration.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from July 1, 2020, to July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation therapy (77290, 77334) rendered on August 16, 2021.  You asked the Plan to waive the coinsurance for radiation therapy. You say that the office told you they would waive any responsibility so you could receive services and now you are receiving a bill. The Plan denied your request. The Plan says you were 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 20% coinsurance for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay $126.28 in coinsurance, which is 20% of the allowed amount for radiation therapy ($631.41 allowed amount x 20% coinsurance = $126.28). Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and 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 radiation therapy (77290, 77334) rendered on August 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the two ambulance services, basic life support, non-emergency transports (A0428), provided May 28, 2021.  You asked the Plan to waive the copayment for the two non-emergency ambulance transports. You say that the ambulance transports were necessary. The Plan denied your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each one-way Medicare-covered ground trip.     The enrollee has been asked to pay a $250 copayment for the two non-emergency ambulance transports. The two non-emergency ambulance transports fall within the Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the two ambulance services, basic life support, non-emergency transports (A0428), provided May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99140) provided on June 24, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified.   We looked at the file and Medicare rules. Code 99140 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99140) provided on June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 26, 2021.  You asked the Plan to pay for the comprehensive oral exam. You say that you switched to a new dentist for your second cleaning of the year. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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 the comprehensive oral exam once every three plan years.   We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam was previously covered on February 4, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the comprehensive oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.  You asked the Plan to pre-approve compression stockings. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested items are not a covered benefit.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are noncovered because they do not meet the statutory definition of a surgical dressing.      Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablet.  You asked the Plan to pre-approve Eliquis. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablet.   Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation therapy services provided on September 17, 2021, and September 20, 2021  

You asked the Plan to waive the coinsurance for the radiation therapy services. You say that the provider would write off the balance for the services but never did. The Plan denied your request. The Plan says the proper coinsurance was 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 20% coinsurance for the cost of Therapeutic services. The total amount allowed was $530.16 with a coinsurance of $106.04 ($530.16 total amount x 20% coinsurance).    

You have been asked to pay a 20% coinsurance for radiation therapy services. The radiation therapy services falls within the Outpatient diagnostic tests and therapeutic services and 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 radiation therapy services provided on September 17, 2021, and September 20, 2021   

Your complaint about your experience with this provider 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of a benign nonodontogenic cyst or tumor (D7461) provided on July 29, 2021.  You asked the Plan to pay for the removal of a benign cyst/tumor. You say that the biopsy provided prior to this service was covered, and you feel this procedure should be covered as well. The Plan denied your request. The Plan says this service is not covered by your dental 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the removal of a benign nonodontogenic cyst or tumor (D7461) provided on July 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a sensor and transmitter (A9276, A9277) for a non-therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve non-therapeutic CGM supplies. You say that this is medically necessary. The Plan denied your request. The Plan says these items are statutorily non-covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-therapeutic CGM supplies have not been met.  Specifically, the requested CGM supplies are associated with a non-therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a sensor and transmitter (A9276, A9277) for a non-therapeutic continuous glucose monitor (CGM).