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

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 18.

You asked the Plan to pre-approve the dental service. You say that the crown is necessary. The Plan denied your request. The Plan says the crown for tooth # 18 is 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 the dental service 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 the dental service. Our reviewer says that the crown for tooth # 18 is not medically necessary. Our physician reviewer found there is partial occlusion on the tooth as the opposing tooth is missing. The reviewer found that the overall stresses to be place on the tooth is low due to the occlusal situation. Given the information in this case, the reviewer found that a full crown for tooth # 18 is not medically reasonable or necessary.

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 the dental service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740 x 3) and core build up (D2950 x 3) provided on February 17, 2021.

You asked the Plan to pay for the dental services. You say that you do not recall receiving a notice that your dental policy was changing. You also say that you need help with this bill. The Plan denied your request. The Plan says the services in this case were performed after your supplemental dental coverage ended. The Plan says that you were not enrolled in the optional supplemental dental coverage on the date of service in this case.

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 optional supplemental dental coverage was not active on the date of service. The Annual Notice of Changes for 2021 shows that the optional supplemental dental coverage was no longer active in 2021. Therefore, we decided that the Plan does not have to pay for the crowns (D2740 x 3) and core build up (D2950 x 3) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost share for the specialist office visit. We decided that the Plan does not have to waive the cost share for the specialist office visit.
You asked the Plan to reduce the cost share for the specialist office visit. You say that this claim was processed incorrectly as in-network and you should have a 20% coinsurance. The Plan says that you have been asked to pay the correct cost-sharing amount.
We decided that the Plan has to reduce the cost share for the specialist office visit.
The Explanation of Benefits shows that the physician is an in-network provider and therefore, the in-network specialist copayment applies.
The Plan says that you must pay a $40 copayment for the specialist office visit. Based on the plan contract, however, you cannot be asked to pay more than a $30 copayment for each visit. Therefore, we decided that the Plan has to reduce the copayment for the specialist office visit from a $40 copayment to a $30 copayment.
We also decided that the Plan does not have to waive the cost share for the specialist office visit.
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 $30 copayment for the specialist office visit. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on January 6, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service (POS) code. 

We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was billed with POS code 12 for the home setting. This POS code is not appropriate for the services at issue. 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 for the office visit rendered on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received March 3, 2021 from the out-of-network provider.
You asked the Plan to pay an additional amount for the periodic oral evaluation and the prophylaxis. You say that your previous dental insurance paid for these services in full, and your current insurance says you have a $0 copayment for these services. The Plan denied your request. The Plan says if you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed with a $0 copayment.
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 payment is in excess of what is covered under this benefit. The Plan contract states that if you choose to see an Out-of-Network dentist you might be billed for charges above what the plan pays, even for services listed with a $0 copayment. The Plan agreed to cover 100% of the allowable amount for the periodic oral evaluation and the prophylaxis. You are responsible for the difference between what was charged by the out-of-network provider and the Plan's allowable amount. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received March 3, 2021 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard - hard appliance, full arch (D9944) received October 20, 2020.

You asked the Plan to pay for the occlusal guard. You say that you have jaw pain and require the occlusal guard. The Plan denied your request. The Plan says this item or service is not covered under your benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the occlusal guard - hard appliance, full arch (D9944) received October 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 4, 2019.
You asked the Plan to pay for the physician's services. 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 physician's services provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on February 10, 2020, to
July 28, 2020, by an OON provider.
You asked the Plan to pay for the office visit. You say that each time you went to this provider he was charging
you copays each time which amounted to $970. The plan representative told you that the Plan will reimburse
you. The Plan denied your request. The Plan says requested information was not received. Enrollee's must
receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
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 had network providers
available who could have provided 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 outpatient office visit provided on February
10, 2020, to July 28, 2020, by an OON provider.
Your complaint about the treatment received by this provider is 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: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy (90834) rendered by the out of network (OON) provider on January 14, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.
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 either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. The provider in this case is not a network provider with the Plan. The service provided was denied by the Plan because prior authorization was not obtained. However, the Plan contract states that the enrollee can choose to receive care from out-of-network providers. The plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. Additionally, according to the contract there is no referral or prior authorization necessary when the enrollee receives care from out-of-network providers. Therefore, we decided that the Plan has to pay for the psychotherapy (90834) rendered by the out of network (OON) provider on January 14, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management provider.

You asked the Plan to pre-approve these services. You say that you need to get your pain pump filled. The Plan denied your request. The Plan says the services are available from network providers.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network pain management provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots (cutting procedure) (D7250) and the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922) received February 3, 2021.

You asked the Plan to pay for the dental services (D7250, D7922). You say that you had a broken tooth that needed to be fixed. The Plan denied your request. The Plan says the requested services (D7250, D7922) are not covered under your supplemental 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 removal of residual tooth roots (cutting procedure) (D7250) and the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site (D7922) received February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bone replacement graft (D4263) provided on February 1, 2021.

You asked the Plan to reimburse you for the bone replacement graft. You say that this service should be covered. The Plan denied your request. The Plan says bone replacement graft is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the bone replacement graft (D4263) provided on February 1, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the screening mammogram rendered on August 6, 2018.
You asked the Plan to waive the copayment for these services. You say that you should have no copayment. The Plan denied your request. The Plan says that the copayment was applied correctly.
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 states that the copayment was applied correctly; however, the Plan has not provided any documentation to support that the services were a diagnostic mammogram for which a copayment would apply. The file supports that this was a covered screening mammogram. Therefore, we decided that the Plan has to waive the copayment for the screening mammogram rendered on August 6, 2018.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the step therapy requirement is not met.
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 states that the step therapy requirement is not met, and the services are not medically necessary; however, no medical records were submitted with the case file. There is no documentation to support that the enrollee has not tried and failed the Plan's required step therapy drugs. Therefore, we decided that the Plan has to pre-approve Prolia.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you cannot see the in-network provider because they are too far away. The Plan denied your request. The Plan says the provider is out-of-network.
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. The record shows there are two in network providers located under 10 miles from you. 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 office visit to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.
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 the enrollee was admitted with infected hip replacement. The enrollee does not have complex wound care requirements and is not on a ventilator. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. 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.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services rendered from January
8, 2021, to January 22, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the provider type is not covered.
The Plan must follow Medicare rules. The rules say that a Licensed Professional Counselor is not eligible to
enroll in Medicare.
We looked at the file and Medicare rules. The file shows that the services were rendered by a Licensed
Professional Counselor. 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 for the outpatient mental
health services rendered from January 8, 2021, to January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 9.
You asked the Plan to pre-approve the dental service. You say that the crown is necessary. The Plan denied your request. The Plan says core build up is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 9.