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

We decided that the Plan does not have to waive the deductible for inpatient services from October 26, 2020,
through November 3, 2020.
You asked the Plan to waive the deductible for inpatient services. You say that the hospital was unable to
perform a necessary surgery so you were sent to a hospital that could. You say that the deductible should be
applied to the hospital stay first which will allow you to get financial assistance for the amount due. The Plan
denied your request. The Plan says the deductible applied correctly.
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 your deductible is $1,000. This is the amount you have to pay out-of-pocket
before we will pay our share for your covered medical services. Until you have paid the deductible amount,
you must pay the full cost for most of your covered services.
The item or service you asked the Plan to waive the deductible for falls within the "Inpatient hospital care"
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000
deductible applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met
at the time inpatient services was received from October 26, 2020, to November 3, 2020. Therefore, we
decided that the Plan does not have to waive the deductible for inpatient services from October 26, 2020,
through November 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the unspecified endodontic service (D3999) provided on January 21, 2021.
You asked the Plan to pay the in-network rate for the unspecified endodontic service. You say that due to Covid-19 your regular dental provider sent you to see another dentist. You also say that out of network claims are covered as in network during the emergency declaration. The Plan denied your request. The Plan says unspecified endodontic service 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 unspecified endodontic service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in-network rate for the unspecified endodontic service (D3999) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from November 4, 2020, to November 18, 2020.
You asked the Plan to waive the copayments for wound debridement. You say that you are shocked by the high charges and thought that you would only owe a specialist copayment. You state that you have a limited income and were not aware that you would owe so much. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.
You received wound debridement at an outpatient hospital facility from November 4, 2020, to November 18, 2020, for a total of 3 services. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $225 copayment per each visit. The total amount you owe is: $225 (copayment) x 3 (wound debridement services) = $675. You have been asked to pay the total copayment amount of $675 for wound debridement. Wound debridement falls within the outpatient surgery and other medical 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 wound debridement provided from November 4, 2020, to November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The
Plan denied your request. The Plan says the item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and removal of impacted tooth provided on November 24, 2020 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray and removal of impacted tooth. You say that you had no choice but to go OON because the treatment was an emergency, and there were no in-network providers available. The Plan denied your request. The Plan says services performed by an OON provider are not covered benefits because your healthcare plan does not have OON benefits. The Plan also says that when you contacted the Plan, you were advised that if you received services OON the services would not be 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, you are responsible for 100% of the cost for dental services received OON. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and removal of impacted tooth provided on November 24, 2020 by an OON provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the enrollee on January 14, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization, which is required both in and out of network. Medicare rules say that plans can require enrollees to get prior authorization. The contract with the Plan says that for outpatient mental health care, prior authorization is required both in and out of network. The Plan did not pre-approve these services. Therefore, we decided that the Plan does not have to pay for out of network outpatient mental health care provided to the enrollee on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires vent weaning,
nutritional management, and daily physician visits. The Plan denied your request. The Plan says the enrollee's
medical needs are being met in the current acute setting.
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 physician
reviewer found that in this case, the enrollee was admitted following cardiac arrest and respiratory failure. She
continues receiving 100% oxygen o the ventilator. She continues to receive acute care services, and these have
not been denied. 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. Therefore, the requested LTACH
services 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam image capture (D0364) provided on January
7, 2021.
You asked the Plan to pay for the dental imaging. You say that you were directed to use this provider by your
usual dentist due to the pandemic. The Plan denied your request. The Plan says they have agreed to cover some
services provided on the date in question; however, a cone beam imaging service is not covered by your dental
benefit, regardless of who renders the services.
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 cone
beam image capture (D0364) provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nursing facility office visit (99309) provided on March 10,
2021, by an OON provider.
You asked the Plan to pay for an office visit. You say that the services were medically necessary. The Plan
denied your request. The Plan says services were provided 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 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. The records provided for review do not show that the services at issue were urgent or
emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we
decided that the Plan does not have to pay for a nursing facility office visit (99309) provided on March 10,
2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the bone and/or joint imaging; whole body (78306), the computed tomography of the abdomen and pelvis (74177), and the computed tomography of the thorax (71260) provided on January 12, 2021 and January 13, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $175 copayment for all other diagnostic and nuclear medicine radiological services and facilities.
You have been asked to pay $350 ($175 copayment x 2) for the diagnostic services provided. If multiple tests of the same type are performed in the same day, one copayment will apply. 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 bone and/or joint imaging; whole body (78306), the computed tomography of the abdomen and pelvis (74177), and the computed tomography of the thorax (71260) provided on January 12, 2021 and January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider
on January 11, 2021.
You asked the Plan to pay for the laboratory services. You say that the emergency room staff gave you the
sample kit to take home and bring back when completed. You say that the bill is an error, and you should not
be responsible for the payment. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan and the services were not approved in advance.
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 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 laboratory services provided by an out-of-network
provider on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services with dental code D8090.
You asked the Plan to pre-approve dental code D8090. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says dental code D8090 is not covered under the Plan's supplemental dental 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-approve dental services with dental code D8090.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you are requesting the clinical criteria used to make this denial. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic continuous glucose monitor.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care from May 14, 2020, to
December 17, 2020.
You asked the Plan to pay for service rendered by a provider who is not eligible to bill Medicare. You say that
these services should be paid by the Plan. The Plan denied your request. The Plan says you did not have prior
authorization and neither the Plan nor Medicare can pay ineligible providers.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who is not eligible to bill Medicare. You
were treated by a Licensed Clinical Professional Counselor for mental health care. This type of counselor is not
an eligible Medicare provider and is not able to bill Medicare or accept Medicare payment structures. Both the
Medicare rules and the Plan contract are clear that these services are not covered and would be your financial
responsibility. Therefore, we decided that the Plan does not have to pay for outpatient mental health care
provided by Cheryl Lynn Howard LCPC, from May 14, 2020, to December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve peritoneal dialysis services (90945) to be provided by
an OON provider.
You asked the Plan to pre-approve peritoneal dialysis services. You say that the enrollee should continue with
the provider he has been seeing for nearly three years. The Plan denied your request. The Plan says there are innetwork
providers that can provide 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-approve
peritoneal dialysis services (90945) to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair for the enrollee.
You asked the Plan to pre-approve a seat lift chair. You say that the enrollee has trouble getting up and out of her current chair. The Plan denied your request. The Plan says that the enrollee does not meet criteria for a lift chair.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. We looked at the file and Medicare rules. The file does not indicate that the enrollee is completely unable to stand up from a regular armchair or any chair in the home. Based on this information, we decided that Medicare rules for coverage of a seat lift chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210), the 2D oral or facial photograph images (D0350 x 4), the oral hygiene instructions (D1330), the gingival irrigation (D4921 x 2), and the unspecified periodontal services (D4999 x 2) provided from February 22, 2021, to February 24, 2021.
You asked the Plan to pay for the complete series x-ray, oral or facial photographic images, oral hygiene instructions, gingival irrigation, and unspecified periodontal services. You say that the provider in this case is in network. You also say that you found this provider listed on the Plan's website. The Plan denied your request. The Plan says the complete series x-ray, oral or facial photographic images, oral hygiene instructions, gingival irrigation, and unspecified periodontal services are not listed as covered services.
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 complete series x-ray, oral or facial photographic images, oral hygiene instructions, gingival irrigation, and unspecified periodontal services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210), the 2D oral or facial photograph images (D0350 x 4), the oral hygiene instructions (D1330), the gingival irrigation (D4921 x 2), and the unspecified periodontal services (D4999 x 2) provided from February 22, 2021, to February 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and the laryngoscopy provided on February 12, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit and the laryngoscopy. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 office visit and the laryngoscopy provided on February 12, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP supplies provided by an out-of-network provider
on December 31, 2020.
You asked the Plan to pay for the CPAP supplies. You say that the supporting documentation will show that
the service was medically necessary and was provided under a physician's prescription. You say that the prior
authorization denial should be overridden, and the claim reviewed for payment. The Plan denied your request.
The Plan says prior authorization was required but not obtained.
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 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 CPAP supplies provided by an out-of-network
provider on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup (D2950).
You asked the Plan to pre-approve a core buildup. You say that you want the Plan to cover this service. The
Plan denied your request. The Plan says the service at issue 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-approve a
core buildup (D2950).