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

We decided that the Plan does not have to pay for the crown (D2750) provided on January 13, 2021.

You asked the Plan to pay for the crown. You say that you were not given an advance notice reason for why the dental rider was cancelled. You also say that this service should be covered.The Plan denied your request. The Plan says you were not enrolled in the dental rider on this date of service.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that you were informed multiple times that your dental rider policy would be terminated due to non-payment of premiums. The record also shows that letters were sent to you on November 9, 2020, December 8, 2020, and January 01, 2021 to inform you that the rider terminated on December 31, 2020 if the premiums were not paid in full.Therefore, we decided that the Plan does not have to pay for the crown (D2750) provided on January 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 16, 2019 by an OON provider.You asked the Plan to pay for the subsequent nursing facility care. You say that this claim was inadvertently sent to the incorrect insurance carrier initially.The Plan denied your request. The Plan says this claim was not received within the allotted time frame of 12 months from the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the subsequent nursing facility care was not filed until October 13, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 16, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), and the unspecified preventive service (D1999) provided on August 27, 2020.You asked the Plan to pay for the dental services. You say that you did not know that you needed to get prior authorization for this dentist. You say that the enrollee is autistic. You say that the enrollee gets very nervous with other dentists. You also say that this dentist knows exactly how to treat him in a calm and proficient way.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network 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, dental service performed out of 
network are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), and the unspecified preventive service (D1999) provided on August 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 13, 2020 by an OON provider.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says this claim was not received withing the allotted time frame of 12 months from the date of service. The Plan also says that proof of timely filing was not submitted.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the subsequent nursing facility care was not filed until January 18, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on January 13, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora medical eye examination (92014) provided on January 11, 2021.You asked the Plan to waive the copayment fora medical eye examination. You say that the service should be covered.The Plan denied your request. The Plan says the correct copayment 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 $35 copayment for vision care. You have been asked to pay a $35 copayment for a medical eye examination. The service at issue 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 a medical eye examination (92014) provided on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the K3 microprocessor knee and foot.

You asked the Plan to pre-approve the K3 microprocessor knee and foot. You say that you would like reconsideration because the requested prostheses are medically necessary. The Plan denied your request. The Plan says the request exceeds the member's need and does not meet the Medicare criteria of reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 the K3 microprocessor knee and foot. Our reviewer says that the documentation doesn't support that the member is a K3 ambulator; therefore, the requested K3 microprocessor is not medically necessary. Our physician reviewer found the member has multiple comorbidities and is expected to require the use of a cane while ambulating.  He is also noted to ambulate up to .5 miles per day and sits 50% of the time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the K3 microprocessor knee and foot have not been met. Therefore, we decided that the Plan does not have to pre-approve the K3 microprocessor knee and foot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora medical eye examination (92004), and an eye refraction (92015) provided on November 16, 2020.
You asked the Plan to pay for a medical eye examination, and an eye refraction. You say that you want the Plan to pay for these services.The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when services are rendered by an in-network provider.We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for coverage of a medical eye examination, and an eye refraction have not been met. Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these services. 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 fora medical eye examination (92004), and an eye refraction (92015) provided on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 20, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the services provided by an out-of-network provider on January 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an OON provider on February 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 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 the services provided by an OON provider on February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), and prophylaxis (D1110) provided on December 2, 2020.
You asked the Plan to pay for the dental services. You say that this claim denied for no coverage. You say that this in incorrect. You also say that your Medicare card dated November 2, 2020 says dental included. The Plan denied your request. The Plan says there is no Mandatory Dental Coverage for the plan that you were enrolled in on the date of service in this case. The Plan also says that you did not enroll in the Optional Supplemental Benefit coverage that is available for an extra charge.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Although the Plan offers an optional supplemental dental benefit, the record shows that you were not enrolled in this benefit on the date of service. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), and prophylaxis (D1110) provided on December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transport (A0434, A0425) provided January 22, 2021.

You asked the Plan to waive the co-payment for the ambulance transport. You say that you do not agree with the co-payment. The Plan denied your request. The Plan says the co-payment was applied correctly

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 co-payment for each Medicare-covered ambulance service.

The enrollee has been asked to pay a $250 co-payment for the ambulance transport. This service falls 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 upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the ambulance transport (A0434, A0425) provided January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) and sinus augmentation with bone or bone substitutes (D7951) provided on September 11, 2019 and October 22, 2019.You asked the Plan to pay for the bone replacement graft and sinus augmentation. You say that you are wondering if these services can be covered under your medical benefit.The Plan denied your request. The Plan says these oral surgical procedures are regarded as medical benefits.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) and sinus augmentation with bone or bone substitutes (D7951) provided on September 11, 2019 and October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from December 17, 2020, through December 29, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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 $200 per day for days 1-5 of a hospital stay.

You have been asked to pay $1,000 ($200 copayment x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from December 17, 2020, through December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on August 11, 2020 by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis. You say that you were told that your insurance would cover your dental work. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no attempt was made by you or the dental provider to verify whether the treating provider was in-network with the Plan prior to this date of 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 requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, and prophylaxis provided on August 11, 2020 by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on November 25, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the services provided to you by an out-of-network provider on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 4, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (Q5106) provided February 5, 2021.

You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services 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.

We find that CPT code Q5106 is not supported in the medical record. Specifically, the records do not detail an
appropriate primary diagnosis for the CPT code billed. Based on this information, we decided that Medicare
rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay
for injections (Q5106) provided February 5, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that this request is medically necessary. The Plan denied
your request. The Plan says step therapy criteria have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Entyvio. Our reviewer says that the
requested service is not medically reasonable and necessary. Our physician reviewer found the Plan requires a
trial of Stelara before they will approve the requested drug. Has the patient tried and failed the required
drug(s)? In this case, the patient has not tried and failed the required drug(s) and there is no documentation
provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse
effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve Entyvio (J3380).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for percutaneous implantation of neurostimulator electrode array; peripheral nerve described by code 64555-25 provided on December 30, 2020.
You asked the Plan to pay for code 64555-25. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
We looked at the file and Medicare rules. Medicare requires that modifier 25 should only be used on claims for evaluation and management services. Code 64555 is considered a surgical code and not an evaluation and management code. Therefore, we decided that the Plan does not have to pay for percutaneous implantation of neurostimulator electrode array; peripheral nerve described by code 64555-25 provided on December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and the ambulance service, basic life support, emergency transport (A0429) provided on December 24, 2020.You asked the Plan to pay for the transportation services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 pay for the transportation services. Our reviewer says that the transportation services are not medically necessary. Our physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The reviewer found that the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, privatecar, or other type of vehicle) were contraindicated for the enrollee on the date of service. The reviewer found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on the date of service. The reviewer also found that documentation does not support that the ambulance transport on December 24, 2020 was medically reasonable and necessary for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met.Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and the ambulance service, basic life support, emergency transport (A0429) provided on December 24, 2020.