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

We decided that the Plan does not have to pre-approve core buildup, including any pins when required, tooth 
#30 (D2950), retainer crown - porcelain/ceramic, tooth #28 and #30 (D6740 x2), pontic - porcelain fused to 
high noble metal, tooth #29 (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit under the plan. 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 are not listed in your EOC as a covered benefit; therefore, the services are not covered. Therefore, we 
decided that the Plan does not have to pre-approve core buildup, including any pins when required, tooth #30 
(D2950), retainer crown - porcelain/ceramic, tooth #28 and #30 (D6740 x2), pontic - porcelain fused to high 
noble metal, tooth #29 (D6240).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 30, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says unauthorized, non-plan care is not covered.  The Plan says that neither the 
referring provider nor the provider of service is a network provider with the Plan. 
 
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 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 provided on July 30, 2020 by an out of network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup for crowns (D2950) on teeth #'s 22 and 
27, and a bone replacement graft (D4263) for tooth site #24. 
 
You asked the Plan to pre-approve the core buildups and bone replacement graft. You say that all requested 
services are necessary for this enrollee. The Plan denied your request. The Plan says the two denied services 
are not covered under the enrollee's dental supplement. 
 
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 pre-approve a 
core buildup for crowns (D2950) on teeth #'s 22 and 27, and a bone replacement graft (D4263) for tooth site 
#24.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on March 12, 2020 to September 12, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you would like this 
taken care of. The Plan denied your request. The Plan says the correct coinsurance has been 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 20% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total amount you are being asked to pay is $378.84. Durable medical equipment falls within the durable 
medical equipment/in-network 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 
durable medical equipment provided by a participating provider on March 12, 2020, to September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 26, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services should be covered because you 
don't believe that authorization and network rules apply here. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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 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 for the medical services provided on June 26, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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. 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 provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an OON provider.

You asked the Plan to pay for nursing facility care. You say that the best possible care was provided to the enrollee in good faith.The Plan denied your request. The Plan says rules for payment have not been met.

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 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formaintenance chiropractic care provided on October 6, 2020.You asked the Plan to pay forthis service. You say that this office visit should be covered by the Plan.The Plan denied your request. The Plan says this service was billed as chiropractic maintenance care which is not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. The provider billed this as maintenance care, which is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay formaintenance chiropractic care provided on October 6, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee from January 14, 2020, to January 16, 2020 and billed under code 99233.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the Nurse Practitioner is asking for payment for dates of services January 14, 2020, to January 16, 2020. Two providers have billed for CPT 99233 on the same dates of service. Payment for services renderedunder code CPT 99233 for the dates in question has already been paid to the Physician. Per the medical records, the Physician is the supervising doctor of Nurse appealing for payment and signs off on Nurse'sreports. Payment to both providers for similar service on the same dates of services is not allowable under Medicare billing requirements unless a separate and distinct services is identifiable. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this service was previously paid to the Physician.  Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee from January 14, 2020, to January 16, 2020 and billed under code 99233.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on August 20, 2020.You asked the Plan to pay forthe dental service. You say that you called the plan to inquire if the provider was in network. You say that you were advised that the provider was in network, but at a different location. You say that after you received the denial, you were advised that the effective contract date for this provider would be September 1, 2020. You also say that you would have rescheduled the appointment if you knew that the provider was out of network when the services were rendered.The Plan denied your request. The Plan says theprovider in this case is an out of network provider at the location you received this service. 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, dental services that you receive out of network are not covered. The record shows that you were advised on July 31, 2020 that the provider in this case was only recognized as a participating provider at the location in Las Vegas, Nevada.Therefore, we decided that the Plan does not have to pay forthe prophylaxis (D1110) provided on August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approveelectrical stimulation device used for cancer treatment, includes all accessories, any type (CPT Code E0766).You asked the Plan to pre-approvethe services. You say that the service is necessary.The Plan denied your request. The Plan says that the service is not necessary.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 services. Our physician reviewer found this patient diagnosed with glioblastoma in 2014 has remained stable with the help of TTF since 2015. The patient has had to take some breaks for nonhealing wounds on their head. Given their unique status of longevity and stability due to the use of TTF is reasonable and medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met.Therefore, we decided that the Plan has to pre-approveelectrical stimulation device used for cancer treatment, includes all accessories, any type (CPT Code E0766).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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient hospital care provided from June 18, 2020, to June 19, 2020.You asked the Plan to pay forthe inpatient hospital care. You say that the services provided were medically necessary.The Plan denied your request. The Plan says the inpatient care provided was unauthorized post-stabilization care.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that this service was not medically necessary. Our physician reviewer found the documentation indicates that the patient was stable for transfer and the services provided were unauthorized post-stabilization care.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 inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient hospital care provided from June 18, 2020, to June 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on February
20, 2019.
You asked the Plan to pay for the subsequent hospital care. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says the appeal was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the subsequent hospital care was not filed until September 1, 2020. This
means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on
February 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer.
You asked the Plan to pre-approve Superion interspinous spacer. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
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 Superion interspinous spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the requested spacer is experimental. More research is needed to show
safety and efficacy. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Superion interspinous spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 15, 2020, by an out-of-network provider.You asked the Plan to pay forthe out-of-network services. Yousay that you saw your regular doctor for an annual wellness check.The Plan denied your request. The Plan says once Medicare has processed the claim, the Plan will process the new claim when received from Medicare.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe medical services provided on July 15, 2020, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on July 28, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that there was a discrepancy withyour listed primary care physician which has been updated. You say that you received a bill because this was denied.The Plan denied your request. The Plan says the copayment 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 copayment per visit for laboratory tests. You have been asked to pay a $10.56, which is less than the standard $20 copayment for the laboratory services. Laboratory 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 forlaboratory services provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora podiatrist office visit (99213) on August 11, 2020.You asked the Plan to waive the copayment fora podiatrist office visit. You say that you are on a fixed income and should be reimbursed for this charge.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 podiatry services. You have been asked to pay a $25 copayment for a podiatrist office visit. Apodiatrist office visit falls within the "Podiatry 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 fora podiatrist office visit (99213) on August 11, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemobile cardiac outpatient telemetry monitoring to be provided by an out of network (OON) provider.You asked the Plan to pre-approvemobile cardiac outpatient telemetry monitoring. You say thatyou would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by an in 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-approvemobile cardiac outpatient telemetry monitoring to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pneumatic compression device provided on July 28, 2020.You asked the Plan to pay forthe pneumatic compression device (E0651). You say that the Plan should pay this claim.ThePlan denied your request. The Plan says the physical exam documents no ulcers or edema.
The Plan follows Medicare rules. The rules state that aPCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for reimbursement.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pay forthe pneumatic compression device provided on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for podiatry services provided.

You asked the Plan to waive the co payment for podiatry services. You say that you disagree with the charges because you did not have relief after all of the visits.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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 co payment for podiatry services. 

You have been asked to pay a $25 co payment for podiatry services. Podiatry services fall within the podiatry services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the co payment for podiatry services provided.

We note your complaint that you did not have relief from the pain. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.