Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care rendered on June 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not separately payable.The Plan must follow Medicare rules. The rules say that preoperative services are included in the global surgical package. We looked at the file and Medicare rules. The file shows that the services were rendered prior to surgical debridement. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe initial hospital care rendered on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride excluding varnish, preventive procedure, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on September 28, 2020.You asked the Plan to pay forthe topical application of fluoride, preventive procedure, and intraoral periapical x-rays. You say that you were never informed that this provider was out-of-network.The Plan denied your request. The Plan says these services 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe topical application of fluoride excluding varnish, preventive procedure, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on September 28, 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 September 10, 2020.

You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. 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 emergency care. Cost-sharing is waived if you are admitted to the hospital. 

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. 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 emergency room visit provided on September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe guided tissue regeneration and bone graft at time of implant placement provided on September 14, 2020.You asked the Plan to pay forthe guided tissue regeneration and bone graft. The Plan denied your request. The Plan says these services 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe guided tissue regeneration and bone graft at time of implant placement provided onSeptember 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency services provided from August
26, 2020, to August 29, 2020.
You asked the Plan to waive the copayment for emergency services. You say that you did not want to go to the
emergency room so the nurse should have made sure you were covered before releasing you. The Plan denied
your request. The Plan says the service was paid for and 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 $90
copayment for Emergency Care.
You have been asked to pay a $90 copayment for emergency services. Emergency services fall within the
Emergency Care benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency services
provided from August 26, 2020, to August 29, 2020.
Please note, the Plan is reviewing the ambulance services separately.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered on April 1, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered on April 1, 2020.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), the consultation (D9310),
the therapeutic parenteral drug (D9610), the initial fifteen minutes of deep sedation (D9222), and the additional
fifteen minutes of deep sedation (D9223) provided on August 26, 2020.
You asked the Plan to pay for the dental services. You say that the dentist got a pre-approval for the services.
You say that you would not have had the procedure done if you were told what the costs were going to be. You
say that these charges are going to hurt you financially. You also say that you feel the plan is misleading. The
Plan denied your request. The Plan says the dental services that you received are not listed as covered services.
The Plan says that any services that are not listed 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, 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
surgical extraction (D7210), the consultation (D9310), the therapeutic parenteral drug (D9610), the initial
fifteen minutes of deep sedation (D9222), and the additional fifteen minutes of deep sedation (D9223) provided
on August 26, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy rendered on October 5, 2020.You asked the Plan to waive the copayment forthese services. You say that you should not have to pay for the endoscopy for every office visit.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 $25 copayment for other Medicare-covered outpatient diagnostic procedures and tests. Review of the file shows that you received an endoscopy on October 5, 2020. You have been asked to pay a $25 copayment for these services. These services fall within the other Medicare-covered outpatient diagnostic procedures and tests 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 endoscopy rendered on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe outpatient surgical services rendered on October 5, 2020 and October 19, 2020.You asked the Plan to waive the copayments forthese services. You say that you should not be responsible for the copayments.The Plan denied your request. The Plan says the copayments were 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 $350 copayment per date of service foroutpatient surgery at an outpatient hospital. Review of the file shows that you received outpatient surgical services in the form of an epidural injection on October 5, 2020 and October 19, 2020. You have been asked to pay a $350 copayment per date of service for these services, for a total of $700. These services fall within the outpatient surgery at an outpatient hospital 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 forthe outpatient surgical services rendered on October 5, 2020 and October 19, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora comprehensive oral examination (D0150) received by the enrollee on November 10, 2020.You asked the Planto pay forthe dental services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is covered once every 36 months.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 comprehensive oral exams once every 36 months.You last received this same service on June 17, 2019. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plandoes not haveto pay fora comprehensive oral examination (D0150) received by the enrollee on November 10, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acutehospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for stroke and acute pyelonephritis. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complexnursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay fornursing facility care provided on April 24, 2020.You asked the Plan to pay fornursing facility care. You say that the Plan should pay this claim.The Plan denied your request. The Plan says Medicare is responsible for payment.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 fornursing facility care provided on April 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

Wedecided that the Plan does not have to pay forthe limited oral exam and pulp vitality test rendered on August 31, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services 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. The Plan covers one limited oral exam per plan year. Pulp vitality testing is not a covered benefit.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 file shows that the enrollee had a limited oral exam on July 20, 2020 for which the Plan approved and paid. The limited oral exam on August 31, 2020 exceeds the Plan limit of one procedure per plan year. The pulp vitality test also rendered on August 31, 2020 is not a covered benefit.Therefore, we decided that the Plan does not have to pay forthe limited oral exam and pulp vitality test rendered on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on July 16, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though these services may be appropriate in this case, neither Medicarenor the Plan covers or pays for these types of items and services.Therefore, we decided that the Plan does not have to pay forthe hearing aids purchased on July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D6058) received on February 10, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is not covered 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 dental services (D6058) received on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forpredictive screening testing provided to the enrollee on June 2, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The Plansaysthe diagnosis code does not substantiate the service.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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the screening test in question is not a Medicare benefit and is therefore denied. It is for predicting response to various medicationsWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forpredictive screening testing provided to the enrollee on June 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acutehospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a non-pressure ulceration of right calf with necrosis of underlying bone. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical therapy (PT) services rendered from August 21, 2020 to September 25, 2020.You asked the Plan to waive the copayments forthese services. You say that you were told you could see an out-of-network provider due to COVID-19.The Plan denied your request. The Plan says the copayments were 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 $35 copayment for Medicare-covered physical therapy and/or speech language pathology visits. Review of the file shows that you received PT services on 11 dates of service from August 21, 2020 to September 25, 2020. You have been asked to pay a $35 copayment per date of service for these services, for a total of $385. These services fall within the Medicare-covered physical therapy and/or speech language pathology visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received PT services on September 14, 2020. Per the contract with the Plan, there is a $35 copayment for Medicare-covered physical therapy and/or speech language pathology visits. However, the Medicare allowed amount for these services was $33.25. Given that the allowed amount was less than the $35 copayment, you have been asked to pay $33.25 for these services.The total amount you have been asked to pay is $418.25. 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 forthe physical therapy (PT) services rendered from August 21, 2020 to September 25, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 29, 2020.
You asked the Plan to pay for the dental services. You say that this should not have been denied. You say that you had this done in order to find a dentist that would accept your coverage. You say that you finally found someone to take your coverage and now it is being denied. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan 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, the frequency limit of 1 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on September 25, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on October 29, 2020.