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

We decided that the Plan does not have to pre-approve a pontic - porcelain fused to predominantly base metal (D6241) and retainer crown - porcelain fused to predominantly base metal (D6751) for tooth 13 and tooth 16.

You asked the Plan to pre-approve pontic and retainer crown for tooth 13 and tooth 16. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered under you 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.

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 pontic - porcelain fused to predominantly base metal (D6241) and retainer crown - porcelain fused to predominantly base metal (D6751) for tooth 13 and tooth 16.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 26, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you cannot afford the charges. 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 $35 copayment for specialist services. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on January 26, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on April 25, 2020.

You asked the Plan to pay for the ambulance 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on April 3, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services provided on April 25, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 home health physical therapy (PT) visits and 4 home health occupational therapy (OT) visits.

You asked the Plan to pre-approve 4 home health PT visits and 4 home health OT visits. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 4 home health PT visits and 4 home health OT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records show that skilled therapy services are not required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4 home health PT visits and 4 home health OT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve4 home health physical therapy (PT) visits and 4 home health occupational therapy (OT) visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 25, 2020 to August 27, 2020 by a non-contracted provider.

You asked the Plan to pay for these services. You say that you were told you would be covered. The Plan denied your request. The Plan says the services were rendered by a non-contracted 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. 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 laboratory services provided on August 25, 2020 to August 27, 2020 by a non-contracted provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fillings on back teeth (D2330 x 8), and a filling on a front tooth (D2391).

You asked the Plan to pre-approve the dental services. You say that the fillings are medically necessary. The Plan denied your request. The Plan says fillings 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve fillings on back teeth (D2330 x 8), and a filling on a front tooth (D2391).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 28, 2021, through January 30, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the cost share 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 $275 copayment each day one through five for inpatient hospital care. You have been asked to pay a $275 copayment each day one through five for inpatient hospital care. This service falls within the inpatient hospital 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 inpatient hospital care provided on January 28, 2021, through January 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustable stance flexion feature (L5845), a fluid swing and stance phase control (L5828), a fluid stance extension (L5848), an endoskeletal knee-shin system (K5856), and an ankle-foot system with microprocessor control (L5973).

You asked the Plan to pre-approve additional features for a lower-limb prosthesis. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says the request for the prosthetic parts exceeds the enrollee's needs and is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional features for a lower-limb prosthesis. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not support that the enrollee's functional level is a K3 or will be a K3. The requested L5845 and codes L5828, L5848, L5856, and L5973 exceed the enrollee's functional need and are not medically necessary, as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional features for a lower-limb prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve an adjustable stance flexion feature (L5845), a fluid swing and stance phase control (L5828), a fluid stance extension (L5848), an endoskeletal knee-shin system (K5856), and an ankle-foot system with microprocessor control (L5973).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts provided on April 17, 2019.

You asked the Plan to pay for the diagnostic casts. You say that you would like this service to be covered. 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. Therefore, we decided that the Plan does not have to pay for the diagnostic casts provided on April 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diagnostic casts (D0470), complete denture - maxillary (D5110), complete denture - mandibular (D5120), occlusion analysis - mounted case (D9950), and occlusal adjustment - complete (D9952).

You asked the Plan to pre-approve diagnostic casts, complete upper and lower dentures and oclussal analysis and adjustment. You say that you have heard good things about this dentist and would like to receive dental services from this dentist. The Plan denied your request. The Plan says you must receive your care from a network provider.

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 diagnostic casts, complete upper and lower dentures and oclussal analysis and adjustment when the services are provided by a network provider.

We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who could provide the items/services at issue in this appeal. We find no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pre-approve diagnostic casts (D0470), complete denture - maxillary (D5110), complete denture - mandibular (D5120), occlusion analysis - mounted case (D9950), and occlusal adjustment - complete (D9952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous therapeutic glucose monitor.
You asked the Plan to pre-approve a continuous therapeutic glucose monitor. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of a continuous glucose monitor have not been met.
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 use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous therapeutic glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous therapeutic glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) and a crown - porcelain/ceramic (D2740).

You asked the Plan to pre-approve core buildup and a porcelain/ceramic crown. You say that you would like the Plan to reconsider coverage. The Plan denied your request. The Plan says these services are not covered under the enrollee's dental 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. 

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 buildup, including any pins when required (D2950) and a crown - porcelain/ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite -three surfaces, anterior (D2332 x2) received September 3, 2020.

You asked the Plan to pay for the resin-based composites. You say that the Plan should pay for the requested services.The Plan denied your request. The Plan says your benefit for the requested service was exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the resin-based composites when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. The Plan has submitted evidence that coverage was provided for two resin-based composites on teeth #11 and #20, on September 3, 2020. The Plan limits coverage of resin-based composites to two per calendar year. The benefit was exhausted when you received two additional resin-based composites on teeth #22 and #27. Based on this information, we decided that the Plan's rules for coverage of the resin-based composites have not been met.Therefore, we decided that the Plan does not have to pay for the resin-based composite -three surfaces, anterior (D2332 x2)received September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a programming device evaluation provided on December 30, 2020.
You asked the Plan to waive the copayment for a programming device evaluation. You say that you disagree with the duplicate charges. 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 $45 copayment for diagnostic procedures and tests. You have been asked to pay the allowed amount of $43.92, which is less than the $45 copayment for a programming device evaluation. A programming device evaluation falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a programming device evaluation provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) received December 28, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you were misled by your dentist who implied the periodontal maintenance would be covered. The Plan denied your request. The Plan says the requested service is not covered under your 2020 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 periodontal maintenance (D4910) received December 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 10, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you were not aware that the drugs would not be covered by your insurance.The Plan denied your request. The Plan says the self-administered drugs are not covered under your Part C benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on February 10, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the 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 periodic oral evaluation (D0120) received July 21, 2020.

You asked the Plan to pay for the periodic oral evaluation. You say that the requested service should be paid for by the Plan. The Plan denied your request. The Plan says at the time of the claim submission to the Plan the frequency of the requested benefit was exhausted.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested payment is in excess of that which is covered under this benefit. The Plan has submitted evidence that they processed claims and paid out for two exams received December 14 and December 31, 2020. These claims were received and processed by the Plan prior to receiving the request for the earlier date of service of July 21, 2020. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) received July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an onlay-porcelain/ceramic-three surfaces (D2643), provided on January 11, 2021.
You asked the Plan to pay for an onlay-porcelain/ceramic-three surfaces. You say that the service should be covered. The Plan denied your request. The Plan says there is no covered for the service obtained.
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. Specifically, the service received is not listed in the Plan's benefit chart, and therefore, is not covered. Therefore, we decided that the Plan does not have to pay for an onlay-porcelain/ceramic-three surfaces (D2643), provided on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on February 22, 2021.

You asked the Plan to pay for the nursing facility visit. You say that the treatment received was medically necessary and the physician provided a statement of medical necessity. The Plan denied your request. The Plan says prior authorization was not requested.

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 nursing facility visit provided by an out-of-network provider on February 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 16, 2020.

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 July 16, 2020.