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

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays, resin-based composite of two surfaces, resin-based composite of one surface, two core buildups, including any pins when required, two crowns, first intraoral periapical x-ray, and additional intraoral periapical x-ray provided on February 27, 2020 to March 5, 2020.You asked the Plan to pay forthe complete series of intraoral x-rays, resin-based composites, core buildups, crowns, and intraoral periapical x-rays. You say that this provider was on the list of in-network providers from the Plan.The Plan denied your request. The Plan says complete series of intraoral x-rays, core buildup, including any pins when required, crown, first intraoral periapical x-ray, and each additional intraoral periapical x-ray are not covered benefits. The Plan also says that the Plan pays 50% of the contracted rate for resin-based composites provided in-network.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, complete series of intraoral x-rays, core buildup, including any pins when required, crown, first intraoral periapical x-ray, and each additional intraoral periapical x-ray are not among those covered under this benefit. The contract also clearly states that you are responsible for a 50% coinsurance for resin-based composites received in-network.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vision supply, accessory and/or service component
of another HCPCS vision code (V2797).
You asked the Plan to pre-approve the vision item/service in other code. You say that your doctor
recommended the multifocal IOL. You do not understand why this lens is not covered when it is necessary to
correct your vision. You live on social security only and cannot afford to pay. The Plan denied your request.
The Plan says this item is bundled into the services provided by the doctor.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code Vision
item/service in other code has a bundled relationship with another code for multifocal intraocular lens and
cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pre-approve
the vision supply, accessory and/or service component of another HCPCS vision code (V2797).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter.You asked the Plan to pre-approve a scooter. You say that you need a new scooter but your physician does not have all your medical records.The Plan denied your request. The Plan says the scooter is being requested for outdoor use and therefore is non-covered.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The record shows that you do not have a mobility deficit that impairs your participation in MRADLs. The record shows you are ambulatory. The file does not show your condition cannot be improved by a wheelchair. The home assessment states you did not use a mobility device and only use your scooter outside.There is no face-to-face documentation from your physician noting your mobility needs inside your home. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a scooter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a combination sit to stand system.
You asked the Plan to pre-approve a combination sit to stand system (E0637). You say that because of your medical conditions you need a standing frame. The Plan denied your request. The Plan says standing frames are specifically excluded from benefit coverage.
The Plan must follow Medicare rules. Medicare does not cover standing frames. Therefore, we decided that the Plan does not have to pre-approve a combination sit to stand system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids (V5258) purchased February 25, 2020 from an out of network provider.You asked the Plan to pay forthe hearing aids. You say that this insurance recognizes and pays for hearing devices and you do not understand why you are notgetting help financially for these.The Plan denied your request. The Plan says hearing aids are not covered when received from an out of network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearingaid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from an in-network provider. We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay forthe hearing aids (V5258) purchased February 25, 2020 from an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on March 12, 2020 by an OON provider.You asked the Plan to pay forthe complete maxillary and mandibular dentures. You say that you were not aware that this provider was not in-network. You also say the representative took your insurance card and said he called the Plan and confirmed the dentures would be covered.The Plan denied your request. The Plan says the treating provider is OON with the Plan. The Plan also says that your policy has no coverage for services provided by an OON 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.Though thePlan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the cost for dental services received from an OON provider. The Plan confirmed that the contact history shows no calls regarding this provider's participation status prior to the services being rendered.Therefore, we decided that the Plan does not have to pay forthe complete maxillary denture and complete mandibular denture provided on March 12, 2020 by an OON provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EGD provided on February 27, 2020. 
 
You asked the Plan to waive the copayment for the EGD. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an EGD on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan. 
 
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 $325 copayment for Outpatient hospital services.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an EGD on February 27, 2020. You have been asked to pay a $325 copayment for the EGD. The EGD falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the EGD provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea tub stool or bench.You asked the Plan to pre-approvea tub stool or bench. You say that you have Parkinson disease and it is difficult to shower.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a tub stool or bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of thisitem.Therefore, we decided that the Plan does not have to pre-approvea tub stool or bench.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain pontic (D6240) and the porcelain retainer crown (D6750) provided on February 14, 2020.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy.
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 items provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain pontic (D6240) and the porcelain retainer crown (D6750) provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoncology services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveoncology services. You say that you would like to continue to see this doctor.The Plan denied your request. The Plan says there are multiple in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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-approveoncology services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty routine transportation trips for the enrollee.
You asked the Plan to pre-approve twenty routine transportation trips. You say that the enrollee is unable to
drive herself to appointments and relies on these services. The Plan denied your request. The Plan says that this
request exceeds the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of thirty (30) trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan does not have to cover routine transportation above the benefit maximum of thirty (30) routine
transportation trips. Therefore, we decided that the Plan does not have to pre-approve twenty routine
transportation trips for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a psychiatric evaluation (90791) provided February 24, 2020.
You asked the Plan to waive the copayment for the psychiatric services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 $40 copayment for Outpatient Mental Health Care. You have been asked to pay a $40 copayment for the psychiatric services. The psychiatric services fall within the Outpatient Mental Health Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a psychiatric evaluation (90791) provided February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on February 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providersavailable who can provide 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 nothave to pay forthe laboratory services provided on February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visits provided from January 24, 2020 to February 21, 2020.
You asked the Plan to reduce the copayment for the specialist office visits. You say that the copayment for the chiropractic visits should be $20. You say you would like to be reimbursed $255. 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 $45 copayment for services obtained from an out-of-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were reimbursed the correct amount.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve pain management. You say that you would like to see this out-of-network
provider because you are not satisfied with the care you received in-network. The Plan denied your request.
The Plan says there are multiple in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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
pain management to be provided by an out of network (OON) provider.
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 you are suffering and need these
supplies. The Plan denied your request. The Plan says this 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 pre-approve core build ups (D2950 x 3).
You asked the Plan to pre-approve the core build ups. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under the
member's contractual policy.
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 services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build
ups (D2950 x 3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 17, 2020.
You asked the Plan to pay for office visit. You say that you were advised that this would be covered. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because this provider is
out-of-network with the Plan.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
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 office visit. Our reviewer says that this visit
does not meet the Medicare criteria for urgent, out-of-are care. Our physician reviewer found review of the
records indicates that this visit was to discuss medication and obtain blood work to assess your diabetic control.
You denied any acute issues. You denied any issues with hypoglycemia or complications related to diabetes.
You could have foreseen requiring this service prior to leaving the Plan's service area. This visit was not
medically necessary. It would have been medically reasonable to delay the service until you returned to the
Plan's service area (or up to 6 months).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of office visit have not been met. Therefore, we decided that the Plan does not
have to pay for an office visit provided on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 3, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 physician services provided on March 3, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), periodic oral evaluation (D0120), and bitewings (D0274) provided on January 13, 2020 by an OON provider.You asked the Plan to pay forthe intraoral periapical x-rays, periodic oral evaluation, and bitewings. You say that this providertold you that they were in-network with your plan, and you are shocked that the Plan only paid $5.00.The Plan denied your request. The Plan says the treating provider is OON with your plan. The Plan also says that first intraoral periapical x-ray (D0220) and each additional intraoral periapical x-ray (D0230) are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, first intraoral periapical x-ray (D0220) and each additional intraoral periapical x-ray (D0230) are not among those covered under this benefit. The contract clearlystates that you are responsible for a $40 copayment for office visits that are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), periodic oral evaluation (D0120), and bitewings (D0274) provided on January 13, 2020 by an OON provider