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

We decided that the Plan does not have to pay for the oral evaluation (D0120), the prophylaxis (D1110), the
initial periapical x-ray (D0220), the additional periapical x-ray (D0230) and the bitewing x-rays (D0274)
provided on February 11, 2020 by an out of network provider.
You asked the Plan to pay for the dental services. You say that upon signing up for this plan, you were never
advised that you needed to use an in network provider for the services covered. You also say that your
insurance was taken by your dentist. The Plan denied your request. The Plan says the provider in this case is
not a network provider with your Dental Plan. The Plan also says that dental services that you receive from an
out of network provider 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 services that you receive out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pay for the oral evaluation (D0120), the prophylaxis (D1110), the initial periapical x-ray (D0220), the
additional periapical x-ray (D0230) and the bitewing x-rays (D0274) provided on February 11, 2020 by an out
of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on December 18, 2019.
You asked the Plan to pay for the prophylaxis. You say that you asked the dentist to ask for these services to be
approved for 4 times a year because you are unable to reach and floss your end molar. You also say that you
were approved for 3 services which is why you made the appointment. The Plan denied your request. The Plan
says this service is limited to two times per calendar year.
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, cleanings are limited to up to 2 per
year. The record shows that you received a prophylaxis on April 10, 2019 and August 14, 2019 and your
cleanings benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the
prophylaxis provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental cleaning (D1110) provided on October 14, 2019.
You asked the Plan to pay for the dental services. You say that the provider took your insurance. The Plan
denied your request. The Plan says they require services be provided by a Dental Network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The service was provided by a
dentist that does not participate as a Dental Network provider. Therefore, we decided that the Plan does
not have to pay for dental cleaning (D1110) provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic evaluation (D0120), prophylaxis adult (D1110) and
bitewings four films (D0274) provided on December 17, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that the Plan should pay the entire bill. The Plan
denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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.
The Plan processed and paid the claim at 100% of the Plan fee schedule amount, which resulted in payment of
$148.25 being paid to the provider. The remaining $69.75 is your liability. Based on the providers billed
amount of $218.00, your liability of $69.75 is the difference between the dentist's fees and the Plan's fee
schedule amount. As this provider is an out-of-network provider with this plan, the difference between the
dentist's fees and the Plan's fee schedule amount is your liability. Therefore, we decided that the Plan does not
have to pay for periodic evaluation (D0120), prophylaxis adult (D1110) and bitewings four films (D0274)
provided on December 17, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections provided on October 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for injections. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that no prior authorization was obtained.
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 has network providers available who can provide 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 injections provided on October 25, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 14, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you should not have to pay the copayment for a follow-up visit and secondary pap smear because the doctor did not get enough cells the first time. 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 $15 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows you received a routine Pap smear on January 17, 2020.
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 office visit provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 25, 2019 by an out-of-network provider.You asked the Plan to pay for the dental services. You say that you were misinformed on the provider participating status.The Plan denied your request. The Plan says there was no information that you or the provider contacted the plan prior to the services 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 has network providers available who can provide 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 dental services provided on September 25, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (Vedolizumab).
You asked the Plan to pre-approve Entyvio. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug requires step therapy.
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 documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Ulcerative colitis, unspecified, without complications. The documentation does not support that the enrollee has tried and failed Stelara. The documentation does not support that Stelara (Ustekinumab) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug. 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 (Vedolizumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on February 5, 2020.
You asked the Plan to pay for the dental services. You say that you were given a list of in network provider and your dentist was not listed. You say you were advised that the coverage would be the same for in network and out of network. You say that no one advised that the stainless steel crown would not be covered. You also say that you are on a limited income. The Plan denied your request. The Plan says prefabricated stainless steel crowns are 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 stainless steel crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 25, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with records. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network
with the Plan and authorization was not obtained.
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 has network providers
available who can provide 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 medical services provided on February 25,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the penile injection (54235) and the penile vascular study (93980) provided on July 24, 2019.You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the copayments have 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 a $70 copayment for each covered diagnostic procedure or test at a network doctor's office. Additionally, enrollees must pay a $50 copayment for each covered specialist office visit.  You have been asked to pay a $70copayment for the diagnostic procedure and a $50 copayment for the specialist office visit 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 copayments for the penile injection (54235) and the penile vascular study (93980) provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a wrist-hand orthosis (L3916) provided to the enrollee on November 26, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a wrist-hand orthosis (L3916) provided to the enrollee on November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from October 15, 2019 to October 17, 2019 and from October 20, 2019 to October 25, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, andjudgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from October 15, 2019 to October 17, 2019 and from October 20, 2019 to October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve distilled water.
You asked the Plan to pre-approve distilled water. You say that your doctor prescribed distilled water for your dry nasal cavities. The Plan denied your request. The Plan says distilled water is an over-the-counter item not generally used for medical purposes.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve distilled water.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 physical therapy services.
You asked the Plan to pre-approve physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is generally not accepted as specific and effective therapy for the enrollee's condition. There is no objective physician evaluation indicating that this patient requires additional therapy for balance or details of the clear cause of the balance disorder to indicate whether therapy will be effective for this condition. There is no documentation of how much prior therapy the enrollee has had for her balance condition which was noted as a chronic longstanding condition. The records do not demonstrate that the requested quantity of therapy for balance is necessary for the enrollee's functional level. The records do not indicate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial denture (D5214).
You asked the Plan to pre-approve the dental services. You say that while cleaning your top bridge, it fell. You say that it no longer fits correctly. You also say that you tripped while walking and lost your lower bridge. The Plan denied your request. The Plan says dentures are covered once every 5 calendar years. The Plan also says that the frequency limit has been reached.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are a covered service, the frequency limit of once every 5 calendar years has been reached. The record shows that the Plan paid for dentures that you received on September 14, 2017. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe core buildup, including any pins when required (D2950).You asked the Plan to pre-approvethe core buildup. The Plan denied your request. The Plan says this service is 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 pre-approvethe core buildup, including any pins when required (D2950).