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

We decided that the Plan does not have to pay for deluxe frames (V2020) purchased December 6, 2019.
You asked the Plan to pay for the frames. You say that the plan's evidence of coverage states "you can get covered eyewear from in-network or out of network providers with submission of paid in full receipts with request for reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-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 purchased from a plan optical facility. We looked at the file and the Plan's rules. enrollee's must receive their medical services from an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the frames have not been
met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) purchased December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) and eye refraction (92015) provided January 9, 2020.
You asked the Plan to pay for the vision services. You say that you feel that these services should be covered by the plan. The Plan denied your request. The Plan says the requested services are not covered under the plan benefits.
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 eye exams and 1 pair of eyeglasses (or contact lenses) after cataract surgery.
We looked at the file and the Plan's rules. The services are not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) and eye refraction (92015) provided January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received from October 22, 2019, to November 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says acupuncture services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture services you received from October 22, 2019, to November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on December 19, 2019, and January 28, 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 providers in this case are not network providers with the Plan. The Plan has network providers available who can provide 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 medical services provided to you by an out-of-network provider on December 19, 2019, and January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) ankle foot orthosis (L1971)
suspension sleeve (L2397) Foot, plastic, heel stabilizer prefabricated off-the-shelf (L3170) provided August
19, 2019.
You asked the Plan to pay for the orthoses. You say that the medical records provided should support the
services in dispute. The Plan denied your request. The Plan says there is no evidence of an established
relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation
and management service and there is no evidence of a prior telehealth service with the ordering physician as
required per CMS guidelines
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 non-covered visit are
likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833)
ankle foot orthosis (L1971) suspension sleeve (L2397) Foot, plastic, heel stabilizer prefabricated off-the-shelf (L3170) provided August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two gingivectomies or gingivoplasties to allow access for restorative procedure provided on December 4, 2019.
You asked the Plan to pay for the gingivectomies or gingivoplasties. You say that this provider is in-network. The Plan denied your request. The Plan says this service is not a covered 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 two gingivectomies or gingivoplasties to allow access for restorative procedure provided on December 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on
December 7, 2019 to December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the SNF services. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor
urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan 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 skilled nursing facility (SNF) services
provided on December 7, 2019 to December 20, 2019 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92004) and Scanning computerized ophthalmic diagnostic imaging (92134) provided December 5, 2019.
You asked the Plan to pay for the vision services. You say that you paid for your co-pay and now you have received a bill from the provider because the plan has not paid and you do not understand why the insurance has not paid for the services. The Plan denied your request. The Plan says the enrollee still has $302.55 remaining to meet towards the deductible.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible. There is still $302.55 remaining in order to satisfy your $500 deductible. The item or service you asked the Plan to pay for falls within the benefit category Vision Care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible. There is still $302.55 remaining to meet towards the deductible. This cost sharing is a contractual obligation that had not been met at the time the vision services was received on December 5, 2019. Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92004) and Scanning computerized ophthalmic diagnostic imaging (92134) provided December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the problem focused limited oral evaluation. We decided that the Plan does not have to pay for the pulp vitality tests.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed the evaluation in order to get the root canal. The Plan says that exams are allowed two times per calendar year and the records show that you had reached the limit for this service. The Plan also says that pulp vitality tests is not a covered benefit.
We decided that the Plan has to pay for the problem focused limited oral evaluation.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable documentation supporting that your exams benefit had been exhausted for this case. Without this information we cannot determine that the
Plan's coverage rules support the denial of payment in this case. Thus, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the problem focused limited oral evaluation.
We also decided that the Plan does not have to pay for the pulp vitality tests.
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, pulp vitality tests are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2) provided on January 22, 2020.
You asked the Plan to pay for the crowns and core buildups. You say that you are on a limited income and are asking for any help to pay for these services. The Plan denied your request. The Plan says these services are not covered under your contract under any normal circumstances.
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 two crowns (D2740 x2) and two core buildups, including any pins when required (D2950 x2) provided on January 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you want the Plan to reconsider their denial of the services. You say that you had fallen and needed help getting up because you are elderly. You stated that the responders only spent twenty minutes with you. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 1, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan 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 laboratory services provided on November 1,
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 pathology services (11102, 88305) provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON pathology services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 pathology services (11102, 88305) provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic treatment (98941AT), electrical stimulation
(G0283), and hot/cold pack therapy (97010) provided on July 3, 2019 to July 8, 2019 by an out of network
provider.
You asked the Plan to pay for chiropractic treatments. You say that you attached medical records for review.
The Plan denied your request. The Plan says the physician is not in the network. The member
must use network providers to receive their medical care and services.
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 a chiropractic treatment (98941AT), electrical
stimulation (G0283), and hot/cold pack therapy (97010) provided on July 3, 2019 to July 8, 2019 by an out of
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services coded as D5865, D6010, D5999, D6052.
You asked the Plan to pre-approve these services. You say that these dental services are medically necessary.
The Plan denied your request. The Plan says it was determined to partially uphold the initial organization
determination denial for D5865 (overdenture complete mandibular), D5999 (unspecified maxillofacial
prosthesis), D6010(surgical placement of implant body: endosteal implant on teeth #21, 24, 27, and 29), D6052
semi-precision attachment abutment on teeth #21, 24, 27, 27, and 29), and D7953 (bone replacement graft
for ridge preservation, per site) as the requested services are not covered benefits under your dental
plan. The Plan states approval has been issued for D7210 (surgical removal of erupted tooth requiring removal
of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated) on teeth #22 and
23 as these are covered dental benefits under the Plan contract.
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, only those services covered under the dental benefit can be
approved under the Plan benefit. Therefore, we decided that the Plan does not have to pre-approve all the
dental services requested.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan of the cervical spine provided on November 4, 2019.
You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says this service was paid for.
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 72125 is not supported in the medical record. Specifically, the records show that the plan has paid for one unit of CPT 72125 on November 4, 2019. The records also show that only one CT scan of the cervical spine was provided on November 4, 2019. The additional unit of CPT 72125 is not supported by the records provided. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the CT scan of the cervical spine provided on November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a PET scan provided on November 21, 2019.
You asked the Plan to waive the copayment for a PET scan. You say that you cannot afford the charges. 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 $225 copayment for advanced imaging. You have been asked to pay a $225 copayment for a PET scan. A PET scan 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 copayment for a PET scan provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on March 16, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that this copayment should be waived due to a delay in durable medical equipment being approved and sent to you. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $40 copayment for specialist visit. You have been asked to pay $40 copayment for specialist visit. 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 an office visit provided on March 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 6, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to urgent care and should not be billed as an emergency room visit. 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 $90 copayment for each Medicare-covered emergency room visit in-network and out-of-network. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were seen in the emergency department.
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 emergency room visit provided by Morton Hospital on February 6, 2020.