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

We decided that the Plan does not have to pay for prophylaxis - adult (D1110), bitewings - two radiographic
images (D0272), comprehensive oral evaluation - new or established patient (D0150) and six (6) periapical xrays
(D0220 and D0230) provided on February 5, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the six (6) periapical x-rays are not listed in your
EOC as covered 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 services: prophylaxis - adult (D1110), bitewings - two radiographic images (D0272) and comprehensive
oral evaluation - new or established patient (D0150) were processed correctly at the in-network level of
benefits for a Comprehensive Oral Evaluation, Bitewing X-rays and Prophylaxis-Adult (Cleaning) which are
payable at 100% of the contracted rate, as indicated in the Evidence of Coverage (EOC) on page 82.
Furthermore, your policy does not cover periapical x-rays, therefore the six Periapical x-rays that the provider
billed denied correctly. The Plan states they contacted the provider and the denied services of the Periapical Xrays
have been written off, and you are not being billed for the services. Therefore, we decided that the Plan
does not have to pay for prophylaxis - adult (D1110), bitewings - two radiographic images (D0272),
comprehensive oral evaluation - new or established patient (D0150) and six (6) periapical x-rays (D0220 and
D0230) provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Expandable Controller and related items (E2311,
E2377, E2313).
You asked the Plan to pre-approve the controller and accessories. You say that the items are medically
necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 controller and accessories. Our
reviewer says that the expandable controller and related items are not medically necessary. Our physician
reviewer found the documentation indicates the patient has sufficient right upper extremity strength and
functional ability to control the power features through their own individual switches therefore the requested
E2311 Electronic connection, E2377 Expandable Controller and E2313 Expandable Controller Harness are not
medically necessary.
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 controller and accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve an Expandable Controller and related items (E2311, E2377, E2313).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye imaging services rendered on
February 12, 2020.
You asked the Plan to waive the copayment for these services. You say that the services should have no
copayment. The Plan denied your request. The Plan says the copayment was applied 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 $65
copayment for each covered diagnostic procedure or test at a network doctor's office.
Review of the file shows that you received scanning computerized ophthalmic diagnostic imaging (SCODI) on
February 12, 2020. Per your contract with the Plan, there is a $65 copayment for each covered diagnostic
procedure or test at a network doctor's office. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. However, the Medicare allowed amount for these services was $40.96. Given
that the allowed amount was less than the $65 copayment, you have been asked to pay $40.96 for these
services.
The file shows that you also received an eye exam that applied a $40 copayment. The SCODI is a separate
diagnostic procedure from the eye exam and has a separate copayment.
Therefore, we decided that the Plan does not have to waive the copayment for the eye imaging services
rendered on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87641, 87798, and 87900 provided on December 12, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 87641, 87798, and 87900 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering physician for the billed tests. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87641, 87798, and 87900 provided on December 12,2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 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 the enrollee by an out-of-network provider on December 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. 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 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 pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you required contact guard assistance with toileting, grooming, and walking 90 feet without assistive device and with a wheelchair following 3 rest breaks. The documentation does not support that you require the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, at a SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 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 the enrollee by an out-of-network provider on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglass frames provided on November 21, 2019 by an out of network provider. You asked the Plan to pay for the eyeglass frames. You say that the Plan should pay this claim. The Plan denied your request. The Plan says out-of-network vision services are not covered. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan does not have to pay vision benefits received from a non-network optical provider. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the eyeglass frames provided on November 21, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on February 19, 2020.You asked the Plan to pay for the panoramic x-ray. You say that you got the panoramic x-ray instead of bitewing x-rays because you are unable to bite down on the bitewing films.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. The only x-rays that are covered by your plan are bitewing x-rays.Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on February 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the spinal injections provided from
January 14, 2020 to February 12, 2020.
You asked the Plan to waive the copayments for the spinal injections. You say that the copayments are a
financial hardship. 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 $200
copayment for each outpatient surgery and/or service at an ambulatory surgical center or outpatient hospital
facility.
You have been asked to pay a $200 copayment for the spinal injections on each date of service. The spinal
injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the spinal
injections provided from January 14, 2020 to February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the real time cardiac telemetry provided on October 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not covered for
screening.
The Plan follows Medicare rules. Medicare rules say that real time cardiac telemetry is medically necessary for
the above indications.
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 services. Our reviewer says that the
requested real time cardiac telemetry services were not medically reasonable and necessary. Our physician
reviewer found that the enrollee has asymptomatic atrial ectopy in the setting of normal ventricular function. In
this circumstance, the documentation of no symptoms or more significant dysrhythmia does not support the
medical necessity for additional cardiac monitoring. Moreover, if additional cardiac monitoring were thought to
be needed, then 24-hour or 48-hour off-line Holter monitoring should be sufficient. Immediate recognition and
reporting of dysrhythmias by a call center associated with mobile cardiac telemetry exceeds the enrollee's
medical needs.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the real time cardiac telemetry provided on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and one extraction to be provided by an oral surgeon.You asked the Plan to pre-approve a consultation and one extraction to be provided by an oral surgeon. 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 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.Review of the file shows that you are requesting a consultation and extraction to be provided by an oral surgeon. The plan only covers dental services when provided by a general dentist. 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-approve a consultation and one extraction to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown for tooth 3.
You asked the Plan to pre-approve a dental crown for tooth 3. 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.
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 covers a dental
crown for tooth 3 when the services are medically necessary and reasonable.
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 a dental crown for tooth 3. Our
reviewer says that the documentation does not support that the requested dental crown is medically reasonable
or necessary. Our physician reviewer found you do not have a diagnosis, condition, and/or symptoms that meet
the Medicare criteria for coverage of crown for tooth 3.
No, the enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for
coverage of crown for tooth 3. The tooth is not reasonably restorable as it presents. A crown needs to have a
finish line on solid tooth strucuture, which is not available on this tooth as prior restoration has been placed to
the level of the bone. A bone cutting procedure would be needed to gain access to solid structure before a
crown could be placed. The requested crown is not standard of care for the treatment of your condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of a dental crown for tooth 3 have not been met. Therefore, we decided that the
Plan does not have to pre-approve a dental crown for tooth 3.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 21, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that you got an infection following a test in the office. You say that the doctor should be responsible. The Plan denied your request. The Plan says the copayment applied 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 $90 copayment up to a maximum for emergency care. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 ER visit provided on December 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcontact lens fitting (92314) provided march 11, 2019.You asked the Plan to pay forthe vision services. You say that the claim was denied for not having authorization. Please review attached medical records to show medical necessity.The Plan denied your request. The Plan says enrollee's must receive their services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 the services are received from an in-network provider. We looked at the file and the Plan's rules. Enrollee's must receive their services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered. 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 forcontact lens fitting (92314) provided march 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora psychotherapy visit provided on February 28, 2020.You asked the Plan to waive the copayment forpsychotherapy visit. You say that you were not treated at this visit.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 $20 copayment for in-network outpatient mental health visit. You have been askedto pay $20 copayment for psychotherapy visit. Psychotherapy visit falls within the Outpatient Mental Health 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 fora psychotherapy visit provided on February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for the requested transfer are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital for hand cellulitis with abscesses. The enrollee has undergone drainage of the abscesses and is receiving antibiotics. The enrollee is not intubated or ventilated. There is no evidence that the enrollee requires services that are not available at the current facility. Medicare overage criteria for transfer are not met. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on January
24, 2020.
You asked the Plan to waive the copayment for these services. You say that the Plan should not be allowed to
assess a copayment for labwork. The Plan denied your request. The Plan says the copayment was applied
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 $10
copayment for per provider per day for in-network Medicare-covered lab services.
Review of the file shows that you received lab services on January 24, 2020. You have been asked to pay a $10
copayment for these services. These services fall within the in-network Medicare-covered lab services benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the laboratory services rendered on January 24,
2020.