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

We decided that the Plan does not have to pre-approve obturator prosthesis care to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve obturator prosthesis care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 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 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 obturator prosthesis care to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the medical services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says there are in-network providers that can render the 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3 extractions (D7140) provided on December 6, 2019.
You asked the Plan to pay for the dental services. You say that the enrollee had 2 teeth that broke off. You say that there was a tooth that was decayed and needed to be removed. You say that the enrollee is in a nursing home. You also say that the enrollee does not have a choice as to which dentist he sees as he is bed-ridden. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services that you receive out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the 3 extractions (D7140) provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, preventive procedure, and prophylaxis provided on August 20, 2020.
You asked the Plan to pay for the bitewings, periodic oral evaluation, preventive procedure, and prophylaxis. You say that past dental work with this same provider has been reimbursed to you. The Plan denied your request. The Plan says the provider who rendered these services is not enrolled in the Medicare program.
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. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, preventive procedure, and prophylaxis provided on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of abdominal and/or pelvic blood flow (93975) performed by a specialist on June 4, 2020.
You asked the Plan to waive the copayment for an ultrasound of abdominal and/or pelvic blood flow. You say that the specialist test copay should be waived. The Plan denied your request. The Plan says the correct copayment 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 $25 copayment for physician specialist services. You have been asked to pay a $25 copayment for an ultrasound of abdominal and/or pelvic blood flow. An ultrasound of abdominal and/or pelvic blood flow falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound of abdominal and/or pelvic blood flow (93975) performed by a specialist on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse more forthe porcelain crown (D2740), and the porcelain fused to predominantly base metal crown (D2751) provided on June 9, 2020.

You asked the Plan to reimburse more forthe dental services. You say that you had several teeth with crowns break off. You say that you thought your insurance would cover more than it did. You also say that you are not going to be able to pay all of your bills next month because of your dental bill.The Plan denied your request. The Plan says 1 crown per calendar year is covered. The Plan also saysthat the frequency limit 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, the frequency limit of 1 crown per calendar year has been exceeded. The record shows that the Plan paid for the crown for tooth # 21 that you received on this date of service.Therefore, we decided that the Plan does not have to reimburse more forthe porcelain crown (D2740), and the porcelain fused to predominantly base metal crown (D2751) provided on June 9, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a queen bed and mattress.

You asked the Plan to pre-approve a queen bed and mattress. You say that you need a new mattress for your chronic pain. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that mattresses are covered only where hospital bed is medically necessary. 

The queen bed and mattress at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a queen bed and mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upholstered portion of the chair, heater or massage unit.
You asked the Plan to pre-approve the upholstered portion of the chair, heater and massage unit. You say that the enrollee is physically unable to get out of a sitting position and needs an electric lift recliner with heater and massage. The Plan denied your request. The Plan says they will approve the seat lift mechanism but the heater and massage unit are not considered reasonable and necessary.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. We looked at the file and Medicare rules. The heater and massage unit does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover the upholstered portion of an electric recliner. Based on this information, we decided that Medicare rules for coverage of the upholstered portion of the chair, heater or massage unit have not been met. Therefore, we decided that the Plan does not have to pre-approve the upholstered portion of the chair, heater or massage unit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe pneumatic compression device you received on February 11, 2020.You asked the Plan to waive the coinsurance forthe pneumatic compression device. You say that you did know know you had to pay this coinsurance.  You stated that you are on a fixed income and you thought that because you had Medicare you would not have to pay anything.The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the pneumatic compression device. The pneumatic compression device falls within the durable medical equipment 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 forthe pneumatic compression device you received on February 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for duplex scans provided on January 17,
2020, and January 24, 2020.
You asked the Plan to waive the coinsurance for duplex scans. You say that you disagree with the charges
because the testing was medically necessary. 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 out-of-network outpatient diagnostic tests and therapeutic services and supplies.
You received a duplex scan on January 17, 2020. The allowed amount is $205.89 and 20% of that is $41.18.
You received a duplex scan on January 24, 2020. The allowed amount is $223.61 and 20% of that is $44.72.
The total amount you owe is: $85.90.
You have been asked to pay the total coinsurance amount of $85.90 for duplex scans. Duplex scans 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 coinsurance for duplex scans provided on January 17, 2020, and January 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient services provided on July 31,
2020 through August 7, 2020.
You asked the Plan to waive the copayment for inpatient services. You say that you have never had to pay a
copay that high before. The Plan denied your request. The Plan says the cost share is correct.
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 per days 1-5 for Inpatient hospital care.
You have been asked to pay a $325 copayment per day 1-5 for inpatient services. These services fall within the
Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient
services provided on July 31, 2020 through August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction provided on June 8, 2020.You asked the Plan to pay forthe extraction. You say that you chose to have the tooth removed because it was cheaper than a root canal. You say that the procedure should be covered.The Plan denied your request. The Plan says the service is not a covered 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 forthe extraction provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis, periodic oral evaluation, bitewing x-rays and oral hygiene instructions provided by an out-of-network provider.You asked the Plan to pay forthe prophylaxis, periodic oral evaluation, bitewing x-rays and oral hygiene instructions. You say that you were told you could go to the dentist to preventive services. You say that you want to be reimbursed.The Plan denied your request. 


The Plan says your plan requires you to receive services from a contracted dentist.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, out-of-network dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe prophylaxis, periodic oral evaluation, bitewing x-rays and oral hygiene instructions provided by an out-of-network.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle. You asked the Plan to pre-approve a scooter. You say that you need a scooter for outside of the home as you cannot walk long distances. The Plan denied your request. The Plan says it is documented that you are able to ambulate in the home with a walker and you have no limitations that would preclude the use of a manual wheelchair in the community. 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 file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. The item at issue in this appeal is being requested for use outside of the home. Also, although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a Group 1 power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.

You asked the Plan to pre-approve these services. You say that you were told you could still undergo surgery with this provider. The Plan denied your request. The Plan says the services are available from network providers.

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. The file shows that you have not been seen by the requested provider for over a year and your care can be safely transitioned to a network provider. 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 a referral to an out-of-network orthopedic surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2D oral/facial photographic image (D0350) provided on July 14, 2020.You asked the Plan to pay forthe 2D oral/facial photographic image (D0350). You say that you are appealing the denial.The Plan denied your request. The Plan says the service is not a covered 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 forthe 2D oral/facial photographic image (D0350) provided on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortelehealth services provided on April 24,2020 by an out of network (OON) provider.You asked the Plan to pay fortelehealth services. You say that you would like this reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained.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 fortelehealth services provided on April 24, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve support pillows (E1399x2). You asked the Plan to pre-approve the support pillows. You say that the medical positioning pillows that are covered do not provide adequate support. The Plan denied your request. The Plan says the requested pillows are not made for a medical purpose and therefore not covered. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve support pillows (E1399x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 physician services provided on February 20, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe magnetic resonance imaging (MRI) that you received on July 21, 2020.You asked thePlan to waive the copayment forthe MRI. You say that you were told you only had a $20 copayment for MRIs.The Plan denied your request. The Plan says you were charged this copayment 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 $195 copayment for diagnostic and nuclear medicine radiological services. You have been asked to pay a $195 copayment for the MRI. The MRI falls within the diagnostic and nuclear medicine radiological 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 magnetic resonance imaging (MRI) that you received on July 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve the medical services. You say that the member was evaluated locally and
has been referred to another location because they could not do the procedure there. The Plan denied your request. The
Plan says there are in-network providers that can render the 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
the medical services to be provided by an out-of-network (OON) provider.