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

We decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and 6 fillings (D2330) provided from June 15, 2020, to July 13, 2020.
You asked the Plan to reimburse you for the dental services. You say that you were never advised that you needed to use a preferred dentist when you signed up for this plan. You also say that you did not know that you needed to find a preferred dentist, or where to find them. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that services are paid according to a maximum allowable fee schedule and you are responsible for all the fees in excess of this amount from the billed amount.
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, you may be billed more by an out of network provider if the charge is greater than the maximum allowable charge. The cost share is a contractual obligation of the plan and cannot be waived. Therefore, we decided that the Plan does not have to reimburse you for the comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), and 6 fillings (D2330) provided from June 15, 2020, to July 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrowns (D2740) for the crowns for teeth # 6 and 10, and the core build up (D2950) for tooth # 6.You asked the Plan to pre-approvethe dental services. You say that the enrollee broke tooth # 10. You say that it needs a full coverage restoration.You say that tooth # 6 had recurrent decay under the crown. You also say that the crown needs to be replaced after restoration is done.The Plan denied your request. The Plan says crowns are covered once per tooth every 5 plan years. The Plan 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, the frequency limit of once per tooth every 5 plan years has been reached. The record shows that you received crowns and core build up for tooth # 6 on May 7, 2019 and a crown for tooth # 10 on March 30, 2019.Therefore, we decided that the Plan does not have to pre-approvethe crowns (D2740) for the crowns for teeth # 6 and 10, and the core build up (D2950) for tooth # 6.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy (45385) provided.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say that the procedure was medically necessary.The Plan denied your request. The Plan says the copayment applied correctly in this case.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 $250 copayment for outpatient hospital services. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. 

The service provided fall within the outpatient hospital services benefit category. The EOC indicates there is a difference between a screening colonoscopy and a diagnostic colonoscopy. In this case, you received a diagnostic colonoscopy and were directed that this would be covered under the outpatient hospital 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 forthe diagnostic colonoscopy (45385) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapeutic parenteral drugs (D9612) on July 2, 2020.You asked the Plan to pay forthe therapeutic parenteral drugs. You say that your anxiety was too much without the help of sedation. You say that you want this extremely large bill paid for.The Plan denied your request. The Plan says the 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 fortherapeutic parenteral drugs (D9612) on July 2, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the injection procedure you had on July 8, 2020.
You asked the Plan to waive the cost sharing for the injection procedure. You say that you were not aware of the deductible. The Plan denied your request. The Plan says you were assessed this cost sharing correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for outpatient procedures and services after your $250 annual deductible is met. Records show that prior to the services on July 8, 2020, you still had $98.10 remaining on our annual deductible. You have been asked to pay this remaining deductible in addition to a $50 copayment for the injection procedure. The injection procedure falls within the outpatient procedures and 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 cost sharing for the injection procedure you had on July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process
stabilization/distraction device, without open decompression or fusion, including image guidance when
performed, lumbar; single level (CPT Code 22869).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says the service is not 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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the device is experimental. More research is needed to show safety and efficacy.
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysician services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvephysician services. You say that this doctor comes highly recommended and you would like to continue care with this provider.The Plan denied your request. The Plan says there are in-network providers available for these 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvephysician services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from April 9, 2020, to May 1, 2020.
You asked the Plan to pay for the SNF stay. You say that the SNF care provided was medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary did not require skilled nursing or therapy services on a daily basis and did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF stay have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) stay provided from April 9, 2020, to May 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), periodic oral evaluation (D0120), prophylaxis (D1110), and first intraoral periapical x-ray (D0210) provided on June 9, 2020.

You asked the Plan to pay for the preventive procedure, periodic oral evaluation, prophylaxis, and first intraoral periapical x-ray. You say that these services are covered benefits under your insurance. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit. The Plan also says that your annual 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified preventive procedure is not among those covered under this benefit. The Plan contract also clearly states that the Plan offers a $500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that the Plan paid $500 toward the dental services you received on February 2, 2020, and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), periodic oral evaluation (D0120), prophylaxis (D1110), and first intraoral periapical x-ray (D0210) provided on June 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe prefabricated post and core (D2954) for tooth #18.You asked the Plan to pre-approvethe prefabricated post and core (D2954) for tooth #18. The Plan denied your request. The Plan says the 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 pre-approvethe prefabricated post and core (D2954) for tooth #18.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interspinous process distraction device (CPT Codes: C1821, 22869, 22870).
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your request. The Plan says the device is not 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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer device remains experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve interspinous process distraction device (CPT Codes: C1821, 22869, 22870).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit provided from January 3, 2020, through January 4, 2020.You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.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 an emergency department visit provided from January 3, 2020, through January 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injections provided on November 12, 2019.
You asked the Plan to waive the coinsurance for the Botox injections. You say that the enrollee is unable to afford this cost sharing. The Plan denied your request. The Plan says this coinsurance was charged correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Botox injections. The Botox injections fall within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Botox injections provided on November 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT Code 73721).
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. The Plan says the MRI is not necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our physician reviewer found the documentation does not support that the noted study is medically reasonable or necessary. Physical examination was unrevealing, and there were no x-rays done to rule out other pathology. Additionally, although the enrollee was continued on medication management of their low back pain/radicular lower extremity pain from the neurosurgeon, there was no documentation of other provider-directed conservative treatment specifically aimed at treatment of the enrollee's knee pain. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, any joint of lower extremity; without contrast material (CPT Code 73721).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible foran X-ray of the hip (73502) performed on June 30, 2020.You asked the Plan to waive the deductible foran X-ray of the hip. You say that you were told by a representative of the Plan that you don't have a deductible.The Plan denied your request. The Plan says the correct cost-sharing was applied.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 $250 deductible for Medicare-covered X-rays. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefitcategory. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for Medicare-covered X-rays. This cost sharing is a contractual obligation that had not been met at the time an X-ray of the hip was received on June 30, 2020.Therefore, we decided that the Plan does not have to waive the deductible foran X-ray of the hip (73502) performed on June 30, 2020.Your complaint about receiving erroneous or ambiguous information regarding cost-sharing from a representative of the Planis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy you had at anoutpatient hospital facility on April 23, 2020.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say that you went in for a routine colonoscopy.The Plan denied your request. The Plan says you had a diagnostic colonoscopy, so the copayments was charged correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that youmust pay a $250 copayment for services in an outpatient hospital facility. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. The medical records from this visit clearly state that this colonoscopy was ordered because of a recent positive Cologuard test.  In addition, the records show that polyps were removed during this procedure.  According to your contract, a screening colonoscopy can become a diagnostic colonoscopy if polyps are found and removed. Therefore, the diagnostic colonoscopy falls within the services in an outpatient hospital facility 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 forthe diagnostic colonoscopy you had at an outpatient hospital facility on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a sleep specialist you had on August 12, 2020. You asked the Plan to waive the copayment for the office visit with a sleep specialist. You say that you shouldn't have to pay this copayment because the physician's assistant saw you. The Plan denied your request. The Plan says you were charged this copayment correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for specialist visits. You have been asked to pay a $45 copayment for the office visit with a sleep specialist. This copayment applies to both physician and practitioner services. 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 with a sleep specialist you had on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that can render the 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.