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

We decided that the Plan does not have to pay for the crown provided on September 2, 2020.
You asked the Plan to pay for the crown. You say that the Plan should pay for these services because the Plan paid for services your husband had done. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pay for the crown provided on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (G0480) provided on August 14, 2020.
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan
denied your request. The Plan says there were network providers available. These services were not preauthorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the lab services (G0480) provided on August 14,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needscan be met at a different level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis (D1110), comprehensive oral evaluation (D0150), complete maxillary denture (D5110), and complete mandibular denture (D5120) provided on December 2, 2019 by an OON provider.You asked the Plan to pay forthe prophylaxis, comprehensive oral evaluation, complete maxillary denture, and complete mandibular denture. You say that the Plan opened a casefor authorization for the enrollee to go to an OON provider. You also say that the enrollee needed new dentures.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there is no documentation that the enrollee was referred to this non-contracted provider by a contracted provider, or that any attempt was made to obtain prior authorization.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe prophylaxis (D1110), comprehensive oral evaluation (D0150), complete maxillary denture (D5110), and complete mandibular denture (D5120) provided on December 2, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that this is for your health issues. The Plan denied
your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2950, D3310) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthese services are 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 Plandoes not haveto pre-approvedental services (D2950, D3310) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture.

You asked the Plan to pre-approve the dentures. You say that you are unable to eat properly. The Plan denied your request. The Plan says this request exceeds the maximum count allowed per period.

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 covers dentures once every five years.

Dentures were last received less than five years ago on February 5, 2019. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the routine eye exam (99213) provided on August 5, 2020, by an out of network (OON) provider.
You asked the Plan to waive the cost share for the routine eye exam. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim processed correctly and no reimbursement is due.
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 these services when they are rendered by an OON provider up to $75. You are responsible for any charge over $75.
We looked at the file and the Plan's rules. The provider has charged $115 for the service provided. Your contract states that you are responsible for any charge over $75. Therefore, your cost share of $40 is correct and the claim has processed correctly. Based on this information, we decided that the Plan's cost share has applied correctly. Therefore, we decided that the Plan does not have to waive the cost share for the routine eye exam (99213) provided on August 5, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveneurostimulator implantation.You asked the Planto pre-approvethe implantation. You say that this is medically necessary.The Plandenied your request. The Plansaysthe request is supported when a team of providers and a mental health expert has done an exam, and determined that the patient is a good candidate for the treatment.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 the implantation. Our reviewer says that the requested implantation is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence-based indicationfor a spinal cord stimulator. Therefore, the request is not medically reasonable or 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 the implantation have not been met.Therefore, we decided that the Plandoes not haveto pre-approveneurostimulator implantation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that you need the stockings to aid in
blood flow in your legs. The Plan denied your request. The Plan says the compression stockings are
noncovered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6533.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past medical history of diabetes and hypertension who presented to the acute hospital on 12/19/2020 with COVID pneumonia. He was treated in the hospital with intubation, mechanical ventilation, dexamethasone and antibiotics for respiratory failure and he required dialysis for renal failure. He is weak and deconditioned and is working with physical and occupational therapy. He is walking only a couple of feet with moderate assistance with a rolling walker and is minimum to moderate assist for transfers and activities of daily living. He is noted to tire quickly with therapy and requires frequent rest breaks. He is reported to be medically stable for discharge. Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to reported poor endurance.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 28, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says they were unable to make a determination
within the allotted time frame.
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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to
pay for the laboratory services provided on February 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided June 29, 2020.
You asked the Plan to pay for the eyeglasses. You say that the bill seems to be for two pairs of eyeglasses. The
Plan denied your request. The Plan says the correct amount was paid.
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 towards a pair of eyeglasses.
We looked at the file and the Plan's rules. The total cost for the eyeglasses was $298.00. A %20 discount was
applied by the provider. The remaining $72 cost is correct. The plan has paid its portion. Based on this
information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we
decided that the Plan does not have to pay for eyeglasses provided June 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoccupationaland physical therapy to be providedby the out-of-network provider.You asked the Plan to pre-approvethe occupational and physical therapy to be provided by the out-of-network provider. The Plan denied your request. The Plan says these services can be provided by a Plan 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 has network providers available who can provide the servicesat issue in this appeal. We found no exception that would require the Planto pre-approve these services. Therefore, we decided that the Plan does not have to pre-approveoccupational and physical therapy to be providedby the out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were 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 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 forthe medical services provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to partially waive the copayment forthe physician office visitprovided on July 23, 2020,butdoes not have to waive the copayment entirely. You asked the Plan to waive the copaymentforthe physician office visit. You say that the provider in question is not a specialist and therefore, you should be charged a $13 copay rather than the $18 copay required for an office visit with a specialist. You also saythat you received a notice from the Plan that the out of pocket costs for all doctors and other care providers were going to be waived from May 1, 2020, until December 31, 2020.The Plan says that this provider does not participate in Medicareand the correct copay amountwas chargedaccording to page 117 of the 2020 EOC.
Wedecided that the Planhas to partially waive the copayment forthe physician office visit.We determined that the provider in question is a family nurse practitioner andnot a specialist. We also did not receive or find evidence to support that the provider in question is a non-par provider, but the copayment charged by the Plan and the information cited reflect the copayment of a specialist's office visit and not a non-par provider. We have determined that the provider in question is not a specialist, andtherefore the $18 copayment for a specialist's office visit cannot apply.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 thePlan clearly says that you must pay a $13 copayment for a primary care physician office visit and an $18 copayment for a specialist's office visit.Because we determined that the provider in question is not a specialist, the appropriate copay amount is $13, and the Plan must partially waive the $18 copay that was charged.However, the Plan is not required to waive the full copayment for the office visit on the date of July 23, 2020. You stated that you received a notice from the Plan that said the out of pocket costs for all doctors and other care providers were going to be waived from May 1, 2020, until December 31, 2020. A copy of this notice was not provided to us and this information is not included in the Plan's 2020 EOC. We cannot verify this information. You may wish to contact your Plan to learn more about any possible waivers of copayments issued outside of the 2020 EOC.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to beprovided by the out-of-network provider.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says cardiology services are available within your health network.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 whocan provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician'sservices to be provided by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 23, 2019, by an
out-of-network (OON) provider.
You asked the Plan to pay for pain management visit. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of payment for this service is correct, because this
provider is out-of-network with the Plan and 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 for the medical services provided on October 23,
2019, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forOphthalmology services (99213) provided on June 12, 2019 to July 5, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe Ophthalmology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not pre-approved and there were network providers available.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 services 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 these services.Therefore, we decided that the Plan does not have to pay forOphthalmology services (99213) provided on June 12, 2019 to July 5, 2019 by an out of network (OON) provider