Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the lab services provided on January 9, 2020.
You asked the Plan to waive the cost share for the services provided. You say that either the lab or doctor's office made an error. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that after your yearly deductible is met, you pay a $10 copay per day, per provider, for Medicare-covered lab services.
The file shows that you received presumptive or definitive drug testing. You were charged $250 to reach your deductible amount. You were then charged a $10 copay. The services fall within the outpatient diagnostic tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible. This cost sharing is a contractual obligation that had not been met at the time the services provided was received on January 9, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the lab services provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe requested dental services.You asked the Plan to pre-approvethese dental services. You say that these services are medically necessary.The Plan denied your request. The Plan says the requested services are not coveredas these services were previously exhausted. Keep in mind this appeal began in 2020 and review crossed over into the new year. 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 services are not available for coverage at this time. Therefore, we decided that the Plan does not have to pre-approvethe requested dental services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on June 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 laboratory services provided on June 12, 2020 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 two additional intraoral periapical x-rays and four 2D oral/facial photographic images provided on July 31, 2020.
You asked the Plan to pay for the additional intraoral periapical x-rays and 2D oral/facial photographic images. You say that you told the provider that your insurance only covered bitewings, and the dentist assured you there would be no charge for the other x-rays. The Plan denied your request. The Plan says these services 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. Therefore, we decided that the Plan does not have to pay for the two additional intraoral periapical x-rays and four 2D oral/facial photographic images provided on July 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia/Denosumab for the enrollee.
You asked the Plan to pre-approve the drug. You say that the enrollee is stable on Prolia treatment. The Plan denied your request. The Plan says there is not enough clinical documentation to support this request.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found a review of the submitted documentation does not include previous treatments, outcomes and adverse reactions trialed. Without the support of the documentation, medical necessity cannot be determined. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia/Denosumab for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglass frames (V2020) provided on August 11, 2020.You asked the Plan to pay forframes. You say that your previous purchase, on Dec. 13, 2018, did not include eyeglass frames and therefore, the allowance for the purchase of frames should have been in place.The Plan denied your request. The Plansays the benefit maximum for this service has been exhausted.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 $150 once every twenty-four months towards the purchase of eyewear.We looked at the file and the Plan's rules. You had exhausted your Plan benefits. Based on this information, we decided that the Plan's rules for coverage of frames have not been met.Therefore, we decided that the Plan does not have to pay foreyeglass frames (V2020) provided on August 11, 2020.Your complaint about potentially not being told you had already exhausted your benefit maximum before the purchace 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic colonoscopy provided on June 26, 2020.
You asked the Plan to waive the deductible for the diagnostic colonoscopy. You say that this procedure was a preventative colonoscopy and should not have coinsurance. 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. Your contract with the Plan says that you have a $750 deductible for covered medical services. The screening colonoscopy became a diagnostic colonoscopy because 4 biopsies were done and sent to Pathology. The item or service you asked the Plan to waive the deductible for falls within the benefit category types of out-of-pocket costs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic colonoscopy was received on June 26, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic colonoscopy provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261) and bone replacement graft (D4263) provided on February 4, 2020.
You asked the Plan to pay for the osseous surgery and bone replacement graft. You say that you have a dental benefit limit of $2,000 for all covered services. You also say that you have received treatment from this provider in the past, and some coverage was provided. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4261) and bone replacement graft (D4263) provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September23, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 laboratory services provided on September 23, 2020 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea swimming pool.You asked the Plan to pre-approvethe swimming pool. You say that you would like reconsideration because this equipment should be covered.The Plan denied your request. The Plan says a swimming pool is not primarily and customarily used to serve a medical purpose.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-approvea swimming pool.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract surgeries provided on July 22, 2020, and August 18, 2020.
You asked the Plan to waive the copayments for cataract surgeries. You say that you were told that you would not owe a copayment for the surgeries. 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 a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You received cataract surgeries at an outpatient hospital facility, on July 22, 2020, and August 18, 2020, for a total of two surgeries. Therefore, you are responsible to pay a $250 copayment per each surgery. The total amount you owe is: $250 (copayment) x 2 (surgeries) = $500. You have been asked to pay the total copayment amount of $500 for cataract surgeries. Cataract surgeries fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for cataract surgeries provided on July 22, 2020, and August 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient radiology services provided on May 6, 2020.
You asked the Plan to waive the copay for the services provided. You say that there were no outpatient facility open due to Covid-19. The Plan denied your request. The Plan says the claim processed 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 $110 copay for basic radiological services in an outpatient hospital. You have been asked to pay a $110 copay for the services provided. The services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the outpatient radiology services provided on May 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam Computed Tomography (CT) scan of the jaw (D0364) provided June 30, 2020.
You asked the Plan to pay for the CT scan of the jaw. You say that this service should be covered. The Plan denied your request. The Plan says this service is not listed as a covered 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 a cone beam Computed Tomography (CT) scan of the jaw (D0364) provided June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 17, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that this does not warrant a copayment because the visit was less than 5 minutes and the nurse only read you results. 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 a $45 copayment for specialist visits. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit 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 a specialist visit provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 19, 2020.
You asked the Plan to pay for the dental service. You say that your tooth was cracked. You say that your mouth was very sensitive to heat and cold. You also say that the dentist was kind enough to see you as soon as possible. The Plan denied your request. The Plan says 1 comprehensive oral evaluation every 3 years is covered. The Plan says that the frequency limit for this service 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 comprehensive oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on December 27, 2018. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement (11721) and the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on June 16, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 services 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 nail debridement (11721) and the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe x-ray services provided on June 11, 2020.You asked the Plan to waive the copay forthe services provided. You say that you would like charges reimbursed.The Plan denied your request. The Plan says you were correctly assessed a copay.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $14 copay for each Medicare-covered standard x-ray service. You have been asked to pay a $14 copay for the x-ray services provided. The services fall within the outpatient diagnostic tests benefit category. Lab and diagnostic tests (radiological and non-radiological) are not waived as part of the Plan's Covid-19 policy. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing isa contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay forthe x-ray services provided on June 11, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forFoundationOne testing provided on August 12, 2020.You asked the Plan to pay forgenetic testing. You say that this testing is covered by Medicare and was medically necessary.The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the Plan may not pay for services from a provider that has opted out of Medicare.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The evidence does not show that either the rendering or order provider have opted out of Medicare coverage. The Plan has notprovided any other rationale to support a denial of payment for this testing. Therefore, we decided that the Plan has to pay forFoundationOne testing provided on August 12, 2020.If the Plan does not agree with our decision,they can ask us to opena 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, wewill send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided.

You asked the Plan to pay for the self-administered drugs. You say that you had brought your current medication with you, but the hospital would not let you bring or take your own medications. You also say that the medications provided and administered by the hospital should be covered.The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided.

Benefits for the self-administered drugs may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided.

You asked the Plan to pay for the first intraoral periapical x-ray. You say that the x-rays were necessary in order to be able to treat the infection.The Plan denied your request. The Plan says this service exceeds the benefit limitation.

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, only 1 x-ray is covered per calendar year. The record shows that you received an x-ray with another office, and your x-ray benefit had been exhausted.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray provided.