Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an EGD provided on March 2, 2021.  

You asked the Plan to waive the copayment for an EGD. You say that you had to have the procedure repeated because the records for the first procedure were lost. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   

We note your complaint that you had to have the procedure repeated due to the provider losing the records for the first procedure. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.  

You have been asked to pay a $325 copayment for an EGD. An EGD 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 copayment for an EGD provided on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for vision care provided on September 27. 2021.  You asked the Plan to waive the copayment for vision care. You say that you are unhappy with how the staff handled scheduling and so you went to another provider for your surgery. 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 $35 copayment for eye exams to diagnose and treat diseases and conditions of the eye for vision care.   You have been asked to pay a $35 copayment for vision care. Vision care falls within the vision 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 vision care provided on September 27. 2021.  We note your complaint about how you are unhappy with how the staff handled scheduling.. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the three additional units of code G0493 for skilled nursing evaluation services provided on July 19, 2021.  

You asked the Plan to pay for the 3 additional units of G0493. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says one unit of G0493 was paid. The other 3 units remain denied as the MUE is exceeded.  

The Plan must follow Medicare rules. Medicare rules say that MUEs with an MAI of 3 may only pay units in excess of the MUE if there is evidence to prove this was correctly billed and was medically necessary.    

In this case, the code G0493 has an MUE of 1, MAI of 3. No records or other documentation were submitted to support that more than 1 unit should be paid. Therefore, we decided that the Plan does not have to pay for the three additional units of code G0493 for skilled nursing evaluation services provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (88312, 88342, 88305, 88313) provided on February 25, 2021.  

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were network providers available.  

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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (88312, 88342, 88305, 88313) provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and fluoride varnish (D1206) provided on July 26, 2021.  You asked the Plan to pay for the dental services. You say that the enrollee did not sign a private contract with the dentist prior to the services being rendered. You also say that the services should be paid. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says payment cannot be made for dental services performed by a dentist that has opted out of Medicare.  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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and fluoride varnish (D1206) provided on July 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for x-ray services (74019, Q0092, R0070) provided on July 2, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for x-ray services. You say that this should be covered. The Plan denied your request. The Plan says this was not authorized.  

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 x-ray services (74019, Q0092, R0070) provided on July 2, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin based composite for a posterior tooth (D2392 x 3) provided on April 23, 2021.  

You asked the Plan to pay for the dental service. You say that you have rarely gone to the dentist because of the coronavirus. You say that you are paying a high premium for dental coverage. You also say that you are upset that this service is not covered. The Plan denied your request. The Plan says resin based composite for a posterior tooth is not listed as a covered dental 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 resin based composite for a posterior tooth is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin based composite for a posterior tooth (D2392 x 3) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on August 16, 2021.  

You asked the Plan to pay for the dental service. You say that you went for your normal check up and cleaning which is covered by your insurance. You say that you had to return on another day to have the service finished. You say that you were never told that this was a deep cleaning. You also say that you were never advised that the service would not be covered. The Plan denied your request. The Plan says the full mouth debridement 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 full mouth debridement is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the full mouth debridement (D4355) provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 01992 provided on July 28, 2021.  

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  

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, the CPT Code Manual definition of code 01992 is anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position.   

We find that CPT code 01992 is not supported in the medical record. Specifically, this anesthesia service is inconsistent with the surgical procedure reported by the surgeon and/or the facility. This means this service is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01992 provided on July 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (screening digital rectal exam and prostate specific antigen test) provided to the enrollee on January 27, 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 the maximum amount of coverage for this service has been received.  

The Plan must follow Medicare rules. The rules say that screening digital rectal exams and prostate specific antigen tests are covered once per year.   

The file shows that these same services were also received on August 11, 2020. The services would not be eligible for reimbursement until August 11, 2021. 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 laboratory services (screening digital rectal exam and prostate specific antigen test) provided to the enrollee on January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the self-administered drugs provided in an outpatient setting from October 25, 2020, to October 26, 2020.  You asked the Plan to reimburse you for the self-administered drugs. You say that you have spoken to plan representatives 5 different times. You say that they have all told you different things regarding this claim. You also say that you should be reimbursed $164.25 for the services in this case. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are 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 reimburse you for the self-administered drugs provided in an outpatient setting from October 25, 2020, to October 26, 2020.   Benefits for the self-administered drugs 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 the complete series x-ray (D0210) provided on July 19, 2021.  

You asked the Plan to pay for the dental service. You say that the full set of x-rays should still be covered. You say that the previous x-ray was necessary and should not prevent your plan from covering this service. The Plan denied your request. The Plan says a full mouth series, bitewing x-rays, or panoramic x-ray, is payable once per calendar year. 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 the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays you received on April 6, 2021. The record shows that bitewing x-rays and a full mouth series x-ray share a frequency limit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the simple extractions (D7140 x 2) and surgical extraction (D7210) provided on July 27, 2021.  

You asked the Plan to pay an additional amount for the dental services. You say that the services you received were approved prior to receiving them. You say that you had the work done. You say that you received a denial a few weeks later. You also say that you cannot eat. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 each year. The Plan also says that the maximum benefit has been exhausted.  

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. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the file shows that the annual maximum benefit has been exhausted. The record shows that the Plan paid for $912.78 for dental services received on July 27, 2021. The record shows that the Plan paid $87.22 for dental services received on June 7, 2021. $912.78 + $87.22 = $1,000. The record shows that the pre-determination letter states that the estimated amount you may owe does not take into consideration deductible, plan maximums, or whether their provider is in or out of network. It also says that benefits will be subject to the deductible and plan maximums at the time services are rendered. Additionally, the pre-determination letter indicates that your Dental Standard Annual Maximum is $1,000 and at the time of predetermination was completed they have used $87.22 of the maximum and $912.78 was still remaining Therefore, we decided that the Plan does not have to pay an additional amount for the simple extractions (D7140 x 2) and surgical extraction (D7210) provided on July 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating hospital facility on July 26, 2021.  

You asked the Plan to waive the copayment for physical therapy. You say that you never had any physical therapy. You say that you just received a paper telling you to receive physical therapy. The Plan denied your request. The Plan says the correct copayments have 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 $195 copayment for outpatient hospital services/other services.    

You have been asked to pay $155.96 which is less than your copayment amount of $195 for physical therapy provided in an outpatient hospital facility. physical therapy falls within the outpatient hospital services/other services 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 physical therapy provided by a participating hospital facility on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 25, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you went to your primary care providers office and no one told you that you would be charged a specialist copayment. 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 $40 copayment for specialist services.   You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office 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 visit provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0669, E0651) to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve the pneumatic compression device. You say that the out-of-network provider's brand of pneumatic compression device is medically necessary. The Plan denied your request. The Plan says there are network providers that can provide the pneumatic compression device.  

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0669, E0651) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Favorable

 We decided that the Plan has to pay for the home visit for the evaluation and management of a new patient (99344) provided on July 25, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says that the service was rendered by an OON provider. The Plan also says that the services were not urgent or emergent, nor were they approved in advance.  

The Plan must follow Medicare rules. 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.  

We looked at the file and Medicare rules. The record shows that the enrollee's plan has a Point-of-Service (POS) option, in which the enrollee can choose to receive services in-network or out-of-network. The 2021 Evidence of Coverage does not state that a prior authorization is necessary for Physician/Practitioner services, and you reasonably believed this service would be covered. Based on this information, we decided that Medicare rules for coverage of the home visit have been met. Therefore, we decided that the Plan has to pay for the home visit for the evaluation and management of a new patient (99344) provided on July 25, 2021 by an out-of-network (OON) 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: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021.  

You asked the Plan to pay for the laboratory services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  

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 the laboratory services provided on April 28, 2021.