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

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that although you can drive,
some of your appointments you are not able to drive yourself because of the medications you currently take.
The Plan denied your request. The Plan says this request exceeds your benefit.
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.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. This request exceeds your benefit
allowance. Your 2021 EOC states up to twenty (20) one-way trips to plan approved locations every year.
Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CardioMEMS procedure.
You asked the Plan to pre-approve CardioMEMS. You say that the enrollee urgently needs this device due to her worsening heart failure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because CardioMEMS is investigational and non-covered.
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 CardioMEMS. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found CardioMEMS has been Food & Drug Administration (FDA) approved and has published literature to support its use in patients in full guideline directed medical therapy who have New York Heart Association (NYHA) Class III symptoms despite medical therapy and a hospitalization within the past 12 months for decompensated congestive heart failure (CHF). The enrollee has a history of ischemic cardiomyopathy, but her last hospitalization was primarily related to chronic obstructive pulmonary disease and responded to appropriate therapy for this. She had no symptoms at follow-up of chronic NYHA Class III CHF described, and she is on a minimal diuretic and medical regimen for CHF.
Based on this she does not meet the published indications for CardioMEMS. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent wheelchair van transportation services (A0130, A0160 (S0209)) provided on December 29, 2020.
You asked the Plan to pay for the wheelchair van transportation. You say that these transportation services were necessary for you to see your medical provider for a follow-up visit. The Plan denied your request. The Plan says wheelchair van services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services or transport in a vehicle that is not an ambulance. The Plan follows the same rule. 
The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergent wheelchair van transportation services (A0130, A0160 (S0209)) provided on December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the health plan's denial of LTACH coverage should be upheld. The enrollee is currently undergoing treatment at an ACH for respiratory distress, in the setting of cerebral palsy. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures coded 97110 and the manual therapy techniques coded 97140 provided on July 31, 2020, August 4, 2020, August 7, 2020, and August 12, 2020.
You asked the Plan to pay for the therapeutic procedures and the manual therapy techniques. 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 supported by the documentation.
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.
The CPT Code Manual definition of code 97140 is manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes. 
We find that CPT code 97110 and 97140 is not supported in the medical record. Specifically, the documentation submitted does not indicate that a total of greater than 8 minutes was spent providing these services. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures and the manual therapy techniques have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures coded 97110 and the manual therapy techniques coded 97140 provided on July 31, 2020, August 4, 2020, August 7, 2020, and August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided March 4, 2021.
You asked the Plan to pay for the tooth extraction. You say that this was a life-saving procedure and should be covered. The Plan denied your request. The Plan says this dental service is not covered under your 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 for extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray, or pay more for the comprehensive oral evaluation, first 15 minutes of deep sedation/general anesthesia, and subsequent 15 minute increment of deep sedation/general anesthesia provided on January 5, 2021 by an OON provider.
You asked the Plan to pay for the panoramic x-ray, and to pay more for the comprehensive oral evaluation, and deep sedation/general anesthesia services. You say that the cost of these procedures should have been covered completely. The Plan denied your request. The Plan says you are responsible for any difference between the Maximum Allowable Fee and the amount the OON provider bills you for the services. The Plan also says that your benefits for the panoramic x-ray have been satisfied and the frequency limitation has been exceeded.
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, full mouth or panoramic x-rays are limited to one procedure code every five years. The record shows that you received a panoramic x-ray on April 12, 2017 and your full mouth or panoramic x-rays benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services that are received OON. The record also shows that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray, or pay more for the comprehensive oral evaluation, first 15 minutes of deep sedation/general anesthesia, and subsequent 15 minute increment of deep sedation/general anesthesia provided on January 5, 2021 by an OON provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services provided on
February 9, 2021.
You asked the Plan to pay for medical nutrition therapy services. You say that the medical nutrition therapy services are medically necessary. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes and renal disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services provided on February 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427,
A0425) received July 13, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the copayment is
too high for an emergency use of the ambulance. 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 $225
copayment for Ambulance Services.
You have been asked to pay a $225 copayment for the ambulance transportation. 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 for
the ambulance transportation (A0427, A0425) received July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Denosumab (J0897)
provided on October 28, 2020.
You asked the Plan to waive the coinsurance for Denosumab. You say that the provider's office informed you
that there would not be any coinsurance. The Plan denied your request. The Plan says the correct coinsurance
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 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay $241.44, or 20% of the Medicare-allowed charge of $1,207.20, for Denosumab.
Denosumab falls 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 treatment with Denosumab (J0897) provided on October 28, 2020.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the eyeglasses (V2784, V2020, V2203, V2750) purchased on March 4, 2021.
You asked the Plan to pay the full amount for the eyeglasses. You say that you were told the payment for the glasses would be less than $200 when you purchased them, so you expected they would be covered in full. The Plan denied your request. The Plan says the cost of the glasses you purchased on March 4, 2021, exceeded the $200 allowance. The Plan paid the full $200 amount, but you are responsible for the costs that exceed the annual allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 to be used towards one pair of eyeglasses (lenses and/or frames), upgrades and contact lenses each year. Members are responsible for all costs over and above the $200 allowance. We looked at the file and the Plan's rules. The record shows that the full cost of the eyeglasses purchased on March 4, 2021, came to $253. The eyeglasses included frames ($28) and two prescription lenses ($130) which both had anti-reflective coating ($55) and polycarbonate coating ($40). ($28 + $130 +$55 + $40 = $253). You have been asked to pay $53 for the eyeglasses. Documentation shows that the Plan has paid the full $200 allowance for this item. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay the full amount for the eyeglasses (V2784, V2020, V2203, V2750) purchased on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mandibular partial denture provided on February 8, 2021.
You asked the Plan to pay more for the mandibular partial denture. You say that you were not aware that this service would not be fully covered. The Plan denied your request. The Plan says you fully exhausted your $375.00 comprehensive dental allowance for the first quarter on this date of service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan offers up to a $375.00 allowance for covered comprehensive dental services every quarter. The record shows that your total benefit allowance of $375.00 was available at the time this service was rendered. The record shows that the full $37.00
quarterly allowance went toward the mandibular partial denture, and your quarterly allowance had been exhausted. Therefore, we decided that the Plan does not have to pay more for the mandibular partial denture provided on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on January 18, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone
replacement graft (D7953) provided on February 8, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary and should be
covered. The Plan denied your request. The Plan says these services are not covered by your 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
guided tissue regeneration (D4266) and bone replacement graft (D7953) provided on February 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received February 8, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you had no choice but to go to the emergency room, and this copayment is too expensive for the short distance you traveled. 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 $225 copayment for Ambulance Services. You have been asked to pay a $225 copayment for the ambulance transportation. 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 for
the ambulance transportation (A0427, A0425) received February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two additional periapical x-ray images (D0230) provided on January 29, 2021.
You asked the Plan to pay for the additional x-ray images. You say that these services were necessary, and you cannot afford this bill. The Plan denied your request. The Plan says only one periapical x-ray can be covered per calendar year. The Plan has paid for the first image (procedure code D0220), however the two additional images (D0230) exceed the benefit's limits and will not be covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover one intraoral (either periapical or occlusal) x-ray procedure code per calendar year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-rays are requested in a frequency that is not covered under this benefit. The Plan provided documentation that they have paid for the first of the three periapical images received on January 29, 2021. The two additional images exceed what is covered under the benefit. Therefore, we decided that the Plan does not have to pay for two additional periapical x-ray images (D0230) provided on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and resin-based composite provided on
December 28, 2020.

You asked the Plan to pay for the panoramic x-ray and resin-based composite. You say that you should be told
if a particular procedure is not covered. You also say that if the Plan approves a provider, then all the services
they provide should be covered. The Plan denied your request. The Plan says these services 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 for the
panoramic x-ray and resin-based composite provided on December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery services provided on January 13, 2021.
You asked the Plan to pay for the services provided. You say that you did not know there was supposed to be an authorization. The Plan denied your request. The Plan says the claim processed correctly.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that some services listed in the Medical Benefits Chart are covered only if the provider gets approval in advanced. We looked at the file and the rules. The Plan did not pre-approve the services at issue in this appeal. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient surgery services provided on January 13, 2021.