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

We decided that the Plan does not have to pay for the partial lower denture (D5214) provided on March 3, 2021.
You asked the Plan to pay for the dental item. You say that you had an appointment for a check-up and you needed upper and lower dentures. You say that you have coverage for dentures every 5 years. You also say that you are on a limited income and you cannot afford to pay this claim. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan also says the annual maximum benefit has been 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 and partial denture is listed as covered, the annual maximum benefit has been exhausted. The record shows that the Plan paid $799.21 for dental services performed on March 3, 2021, $137.81 for dental services performed on January 18, 2021, and $62.98 for dental services performed on January 19, 2021. Therefore, we decided that the Plan does not have to pay for the partial lower denture (D5214) provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the out-of-area urgent care visit provided by an out-of-network
provider on January 13, 2021.
You asked the Plan to pay for the urgent care visit. You say that you were in extreme pain and your blood
pressure was dangerously high. You say that you tried to find an approved urgent care and there wasn't one.
The Plan denied your request. The Plan says that this provider is not a network provider with the Plan, the
service was not urgent, and the service was not approved in advance.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The records show this was an out-of-area urgent care visit. The Plan did not
submit medical records to justify their denial that this was not urgent. Therefore, we decided that the Plan has
to pay for the out-of-area urgent care visit provided by an out-of-network provider on January 13, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on January 14, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 continuous glucose monitor (CGM) supplies rendered on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative monitoring services rendered on November 16, 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 procedure code 95941 is not supported.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code 95941 has a status indicator of I and is not valid for Medicare purposes. 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 continuous intraoperative monitoring services rendered on November 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment applied for the wrist
endoscopy surgery (29848) provided on October 12, 2020.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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 $300
copayment for each Medicare-covered outpatient surgery service at an outpatient hospital.
You have been asked to pay a $300 copayment for the Medicare-covered outpatient surgery service provided at
an outpatient hospital. 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 issue reimbursement of the copayment applied for the
wrist endoscopy surgery (29848) provided on October 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transportation (A0428, A0425) received December 31, 2020.You asked the Plan to waive the copayment forthe ambulance transportation. You say that you should not have to pay for the ambulance transportation.The Plan denied your request. The Plan says the correct cost share applied to the claim.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 $250 copayment for Ambulance Services. You have been asked to pay a $112.78 copayment for the ambulance transportation, which is less than the $250 copayment listed in your Evidence of Coverage. The ambulance transportation falls within the Ambulance 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 forthe ambulance transportation (A0428, A0425) received December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on March 8, 2021 by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that your plan covers services from either in-network or OON providers. You also say that you did not receive anything that says you would be charged a higher cost for OON dental services. The Plan denied your request. The Plan says the total $90.00 amount applied correctly as your liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.

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 the difference between the billed amount and allowed amount. The record shows that your Summary of Benefits refers you to the Evidence of Coverage for limitations, exclusions, and restrictions that may apply. It also advises that cost sharing for OON providers may be higher. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on March 8, 2021 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapeutic exercises (97110) provided on July 7, 2020.You asked the Plan to pay fortherapeutic exercises. You say that this should be covered at the in-network level.The Plan denied your request. The Plan says this was not billed correctly.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, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows that this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay fortherapeutic exercises (97110) provided on July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on January 28, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that you would not owe anything for the Medicare Part B drugs. 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on January 28, 2021. The total allowed amount is $3,408.95 and 20% of that is $681.79. You have been asked to pay the total coinsurance amount of $681.79 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided on January 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the physical therapy services provided on
April 18, 2019.
You asked the Plan to waive the cost share for the services provided. You say that you cannot understand why
you were billed a deductible in the middle of the year for the same service. The Plan denied your request. The
Plan says the deductible was 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 there is a $185 deductible.
We looked at the file and the rules. The service you asked the Plan to waive the cost share for falls within the
outpatient rehab services benefit category. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is a $185 deductible. This cost sharing is a contractual obligation that had not been met at the
time the claim was processed for the services. The records show that a previous claim was reprocessed, which
meant you no longer met the deductible amount. Therefore, we decided that the Plan does not have to waive the
cost share for the physical therapy services provided on April 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided on November 30, 2020.
You asked the Plan to waive the copay for the services provided. You say that the hospital did nothing to help you. The Plan denied your request. The Plan says the original claim processed correctly with a copay.
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 $90 copay for each emergency room visit. Although the visit did not produce the outcome you were hoping, the medical records do show that services were provided on the date at issue. You have been asked to pay a $90 copay for the services provided. The services fall within the emergency 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 copay for the emergency room services provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic - porcelain/ceramic (D6245), and the retainer crown - porcelain/ceramic (D6740) received February 1, 2021.

You asked the Plan to pay for the pontic - porcelain/ceramic and the retainer crown - porcelain/ceramic. You say that you thought your Plan included dental coverage. The Plan denied your request. The Plan says the benefit includes dental coverage however the requested services are not covered under this 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. The services covered under the Plan's supplemental dental benefit can be found on page 83 of the 2021 EOC. Therefore, we decided that the Plan does not have to pay for the pontic - porcelain/ceramic (D6245), and the retainer crown - porcelain/ceramic (D6740) received February 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinjection of biodegradable material next to prostate (55874), ultrasonic guidance for administration of radiation therapy (76965), radiation therapy plan (77318), radiation treatment device (77332), radiation therapy consultation (77370), special radiation treatment procedure (77470), application of radiation source (7778), and radioelements (Q3001)You asked the Plan to waive the copayment forradiation therapy. You say that the cost share is incorrect.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 20 % coinsurance for radiation therapy and supplies and $45 copayment for specialist office services. for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a 20 % coinsurance for radiation therapy and supplies and $45 copayment for specialist office services. for radiation therapy. These services fall 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 forinjection of biodegradable material next to prostate (55874), ultrasonic guidance for administration of radiation therapy (76965), radiation therapy plan (77318), radiation treatment device (77332), radiation therapy consultation (77370), special radiation treatment procedure (77470), application of radiation source (7778), and radioelements (Q3001)
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 2, 2020.
You asked the Plan to pay for the office visit. You say that previous claims were paid. The Plan denied your request. The Plan says previous claims were paid in error, and they cannot pay a provider who is not eligible to participate in Medicare.
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 has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee is unable to take oral medicaitons. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an oral bisphosphonate drug and zoledronic acid before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the x-rays and injections provided from July 14,
2020, through August 14, 2020.
You asked the Plan to waive the cost for the x-rays and injections. You say that the advertisement stated that
copayments for medical services were being waived until the end of September 2020. You say that you
confirmed before each visit that there would be no cost to you. The Plan denied your request. The Plan says the
cost share 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 $14
copayment for each Medicare-covered standard x-ray service and 20% coinsurance for each Medicare-covered
Part B drug from an in-network provider.
You have been asked to pay a total of $250.01 for the x-rays and injections. The x-rays fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit
category. The injections fall within the "Medicare Part B Prescription Drugs" benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. The Plan says that only
copayments for primary care services were being waived. 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
cost for the x-rays and injections provided from July 14, 2020, through August 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance services (A0427) provided on February 6, 2021.
You asked the Plan to waive the copayment for the emergency ambulance transportation. You say that you see that you can get 12 one-way trips for non-emergent transportation, and you say this was not an emergent situation. You say you had COVID-19 and could not drive yourself due to the symptoms. The Plan denied your request. The Plan says the cost-sharing was applied correctly for this service.
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 $150 copayment for ambulance services.
You have been asked to pay a $150 copayment for the emergency ambulance transportation. You feel that you should be charged the $0 copay for the routine transportation listed under the transportation benefit. The transportation benefit applies to foreseen circumstances, such as a pre-planned doctor's appointment, where you need transportation for medical-related purposes. The Plan's rules for this benefit state that trips must be pre-approved and planned at least three days in advance, and generally routine transportation is provided in a vehicle other than an ambulance. In this case, you took an ambulance to the hospital due to acute COVID-19 symptoms. These required services were not foreseen, were provided due to an acute medical condition, and were billed by the provider and approved for coverage as emergent transportation.
Emergency ambulance transportation falls within the ambulance 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 emergency ambulance services (A0427) provided on February 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal scaling and root planing (D4342 x2), and an unspecified preventive procedure (D1999 x2) provided from January 28, 2021, through February 10, 2021.You asked the Plan to pay forperiodontal scaling and root planing, and an unspecified preventive procedure. You say that you were not aware that these services would not be covered.The Plan denied your request. The Plan says the services at issue 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forperiodontal scaling and root planing (D4342 x2), and an unspecified preventive procedure (D1999 x2) provided from January 28, 2021, through February 10, 2021.