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

We decided that the Plan does not have to waive the deductible for the chiropractic treatment provided on October 14, 2020.

You asked the Plan to waive the deductible for the chiropractic treatment. You say that you have already met your $200 deductible. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 there is a $200 deductible that applies towards in-network chiropractic treatments. 

The chiropractic treatment you asked the Plan to waive the deductible for falls within the "Chiropractic Services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 deductible that applies towards in-network chiropractic treatments. This cost sharing is a contractual obligation that had not been met at the time the chiropractic treatment was received on October 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the chiropractic treatment provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete upper denture (D5110), and the partial lower denture (D5214) provided on January 26, 2021.
You asked the Plan to pay for the oral evaluation and dentures. You say that you lost your dentures. You say that they went down the garbage chute. You say that you need replacement dentures. You also say that you cannot afford a new pair out of pocket. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered per 3 plan years. The Plan says that dentures are covered once every 5 plan years. The Plan also says that the frequency limits have been exceeded for these 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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on July 16, 2018. The record shows that the Plan paid for a complete upper denture and a partial lower denture that you received on July 25, 2018. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the complete upper denture (D5110), and the partial lower denture (D5214) provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 27, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told there would be no charge for a surgical follow-up visit. You say your entire hand was checked and there was no additional treatment other than a splint which you have paid for. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for medical care or surgery services in a specialty physician's office. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows evaluation, diagnosis, and treatment of your left thumb which was unrelated to the re-evaluation of your left middle finger. 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 specialist office visit provided on January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image (D0230), and the intraoral - periapical first radiographic image (D0220) received January 20, 2021.
You asked the Plan to pay for the intraoral - periapical each additional radiographic image and the intraoral - periapical first radiographic image. You say that the requested services were necessary. The Plan denied your request. The Plan says the requested services 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 intraoral - periapical each additional radiographic image (D0230), and the intraoral - periapical first radiographic image (D0220) received January 20, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for telehealth therapy visits.

You asked the Plan to waive the co-payment for telehealth therapy visits. You say that you believe you should still have your co-payments waived. The Plan denied your request. The Plan says although they previously waived co-payments, this policy is no longer applicable.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 co-payment for telehealth therapy services.

You have been asked to pay a $30 co-payment for telehealth therapy visits. This service falls within the telehealth therapy 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 co-payment for telehealth therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 20, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation, panoramic x-rays, and prophylaxis provided on December 2, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive periodontal evaluation, panoramic x-rays, and prophylaxis. You say that a Plan customer service representative advised you that this provider was in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no contacts were made to the Plan prior to this date of service to verify benefits and provider eligibility.
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 rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation, panoramic x-rays, and prophylaxis provided on December 2, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 17, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that the provider did not do anything for the enrollee at the time of the visit and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for specialist visits. The medical records show that the enrollee had a specialist visit on November 17, 2020. Therefore, the enrollee is responsible to pay the $45 copayment. The enrollee has been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive 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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that definitive drug testing is covered when specific
criteria are met.
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 these services. Our reviewer says that the
testing was not medically necessary. Our physician reviewer found the enrollee was referred for drug testing
and received presumptive and definitive drug testing. The submitted documentation does not support that the
Medicare criteria for coverage of the definitive drug testing are met. The testing was therefore not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the definitive drug testing rendered on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (COVID protection equipment) (D1999) provided on December 3, 2020.

You asked the Plan to pay for the COVID protection equipment. You say that it is unacceptable that you are being charged for dental services when the Plan promises to cover them. You are upset because you changed your dentist to an in-network provider and this service is still not covered. The Plan denied your request. The Plan says the dental x-rays and evaluation are covered in full, however dentists are allowed to report the cost of additional infection control procedures and personal protective equipment under code D1999 due to the pandemic. An individual dentist determines whether to charge a fee for infection control procedures and personal protective equipment along with determining the fee amount. The fee amount the dentist can charge is not set by the ADA or a third-party payer and is not covered by 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 pay for the unspecified preventative procedure (COVID protection equipment) (D1999) provided on December 3, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit provided on August 4, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable.
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. Review of the file shows that the file is largely incomplete. The documentation
does not support why the claim was denied. The only documentation provided states that "this procedure is
only covered when used according to FDA recommendations." No additional details were provided as to why
this claim was denied. The Plan has not substantiated their denial. Therefore, we decided that the Plan has to
pay for the emergency department visit provided on August 4, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness is used to control power options through a joystick and standard power options come with their own switches.
Review of the file shows that the enrollee is independent with self-feeding and has bilateral arm strength adequate to control the approved power options without the addition of the expandable controller and harness. The electronic connection is not covered, as the approved power options already contain their own switches. 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 pre-approve an expandable controller with harness and electronic connection for a power wheelchair (PWC).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the medical records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee has no skilled therapy or skilled nursing needs, therefore does not meet the Medicare coverage guidelines.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00813 provided on October 21, 2020.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 00813 is not supported in the medical record. Specifically, the documentation supports that the enrollee was inpatient for this date of service. This claim was billed with a place of service of 22 (outpatient), which is an inappropriate place of service based on the documentation. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00813 provided on October 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.

You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says Vertiflex surgery is not medically necessary as the current medical literature indicates the service is considered experimental and investigational.

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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 68-year-old female who is being treated for spinal stenosis lumbar region with neurogenic claudication. She continues with back pain and neurogenic claudication with spinal stenosis. Although the Vertiflex surgery might be helpful for the enrollee's condition, current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for several extractions (D7140, D7210) and an immediate upper denture (D5130) provided on October 8, 2020 by an out-of-network provider.
You asked the Plan to pay for the extractions and dentures. You say that you chose to use an out-of-network dentist because the price you were quoted was less than the in-network dentist. You feel the Plan should still pay part of the cost. The Plan denied your request. The Plan says out-of-network dental care is not covered. When you receive dental services out-of-network, you will be responsible for 100% of the cost.
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 does not cover dental services provided out-of-network. Though the Plan offers a dental benefit in excess of Medicare coverage, only services provided in-network may be eligible for coverage under this benefit. Therefore, we decided that the Plan does not have to pay for several extractions (D7140, D7210) and an immediate upper denture (D5130) provided on October 8, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services received on October 27, 2020, by
an OON provider.
You asked the Plan to pay for the dermatology services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when
provided by an OON provider.
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 dermatology services received on October 27,
2020, by an OON provider.