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

We decided that the Plan does not have to pre-approve an endosteal implant (D6010), bone replacement graft
(D7953), a custom fabricated abutment (D6057), and an implant stent (D6191).
You asked the Plan to pre-approve the implant, bone replacement graft, custom fabricated abutment, and the
implant stent. You say that the enrollee has serious health issues including epilepsy and RSD. You say that the
enrollee's tooth has a fractured root and is not restorable. You say that an extraction and implant under sedation
are necessary to restore the enrollee's oral health to optimal levels. The Plan denied your request. The Plan says
implant, bone replacement graft, custom fabricated abutment, and the implant stent are not listed as covered
services.
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 an
endosteal implant (D6010), bone replacement graft (D7953), a custom fabricated abutment (D6057), and an
implant stent (D6191).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided by provider on December 29, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges because your pacemaker malfunctioned.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 $50 copayment for emergency care. You have been asked to pay a$50 copayment for an ER visit. An ER visit falls within the emergency 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 an ER visit provided by provider on December 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation, including an oral evaluation (D9310), and the surgical stent (D5982) provided on November 13, 2019 by doctor.You asked the Plan to pay forthe dental services. You say that you were advised that the services would be covered. You say that the provider's office advised there was a referral for you. You also say that you have a referral from your medical doctor.The Plan denied your request. The Plan says the consultation, including oral evaluation, and the surgical stent are not listed as covered services.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 adental benefit in excess of Medicare coverage, the requested dental services are not among those covered under this benefit. Additionally, there is no evidence that a referral was provided for the services.Therefore, we decided that the Plan does not have to pay for the consultation, including an oral evaluation (D9310), and the surgical stent (D5982) provided on November 13, 2019 by doctor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to enrollee from October 7, 2019 to October 13, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The claims were not billed with the required TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the home health services rendered to enrollee from October 7, 2019 to October 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the benralizumab injection and the therapeutic injection provided on October 11, 2019.
You asked the Plan to waive the coinsurance for the benralizumab injection and the therapeutic injection. You say that you do not agree with the claim. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B Covered Drugs from an in-network provider.
You have been asked to pay a total of $1,073.27 for the benralizumab injection and the therapeutic injection.

The benralizumab injection and the therapeutic injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for the benralizumab injection and the therapeutic injection provided on October 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for PT provided on September 11, 2019.
You asked the Plan to waive the deductible for PT. You say that you disagree with the charges. 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. Your contract with the Plan says that there is a $1,000 deductible for out-of-network outpatient rehabilitation services. You received PT from an out-of-network provider on September 11, 2019. The record shows that you had paid $456.79 toward the $1,000 deductible. Therefore, you are responsible to pay the allowed amount of $88.45. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for out-of-network outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time PT was received on September 11, 2019. Therefore, we decided that the Plan does not have to waive the deductible for PT provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit. You asked the Plan to pre-approve chiropractic visit. You say that you desperately need permission to see this doctor. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no proof of subluxation of the spine and this service is not covered when performed by a chiropractor. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The record does not show that you have subluxation of the spine. Therefore, we decided that the Plan does not have to pre-approve an office visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you need these foot inserts but do not need an attached brace.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
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 cardiology visit. You say that it is medically necessary for the member to continue treatment with this provider to assure the best possible outcome with their condition. The Plan denied your request. The Plan says the services the member requires are readily available and accessible within the Plan's 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a moist electric heating pad.
You asked the Plan to pre-approve the pad. You say that this will help alleviate pain. The Plan denied your
request. The Plan says that this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a moist electric heating pad is not covered by
Medicare.
This request is statutorily not covered. Based on this information, we decided that Medicare rules for coverage
of the pad have not been met. Therefore, we decided that the Plan does not have to pre-approve a moist electric
heating pad.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fora the SNF stay provided from October17, 2019 to November 6, 2019.You asked the Plan to waive the copayments for the SNF stay. You say that you cannot afford this bill for the skilled nursing services. The Plan denied your request. The Plan says the claim for November 1, 2019 to November 6, 2019 was reprocessed to reflect a $100 copayment and you have been charged the correct cost sharing 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 $20 copayment per day, per admission for days 1-20 and a $0 copayment per day, per admission for days 21-100. You have been asked to pay a total of $400 for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) 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 copayments for the SNF stay provided from October 17, 2019 to November 6, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for oral hygiene instruction (D1330) provided November 7, 2019.
You asked the Plan to pay for oral hygiene instruction. You say that you are appealing the denial of the claim. It was for deep cleaning of your teeth and the booklet says the plan pays up to 2 cleanings per year. The Plan denied your request. The Plan says the requested 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 for oral hygiene instruction (D1330) provided November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoCycle Home functional electrical stimulation (FES) cycling therapy system.
You asked the Plan to pre-approve a MyoCycle Home FES cycling therapy system. You say that this is necessary to prevent muscle atrophy due to the enrollee's paralysis resulting from her spinal cord injury. The Plan denied your request. The Plan says this type of treatment is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. We looked at the file and Medicare rules. The record shows that the enrollee has a spinal cord injury. NMES/FES is not covered to prevent atrophy when the nerve supply to the muscle is intact. Based on this information, we decided that Medicare rules for coverage of a MyoCycle Home FES cycling therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoCycle Home functional electrical stimulation (FES) cycling therapy system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for 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 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 medical services provided to the enrollee by an out-of-network provider on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 21, 2019.
You asked the Plan to pay for the dental service. You say that you were advised by the provider's office that the
provider was participating with the plan. You also say that a plan representative recommended you to this
provider in the first place. The Plan denied your request. The Plan says dental services must be provided by an
active, participating provider. The Plan also says that the provider in this case was not a network provider on
October 21, 2019.
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 must be provided by an
active, participating provider in order to be covered. The record shows that the provider's participating status
did not change to in network until October 22, 2019. Therefore, we decided that the Plan does not have to pay
for the panoramic x-ray (D0330) provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and
supplies.
You asked the Plan to pre-approve a CGM and supplies. You say that this is medically necessary. The Plan
denied your request. The Plan says that the enrollee does not meet criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above
criteria have been met.
We looked at the file and Medicare rules. The file indicates the enrollee is not testing her blood glucose four or
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6
continuous glucose monitor (CGM) and supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered to the enrollee from October 30, 2019 to November 6, 2019.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 are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy rendered to the enrollee from October 30, 2019 to November 6, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 11, 2019.
You asked the Plan to pay for the physician's services. You say that you have been seeing this provider since the 70's and it would be a hardship to go anywhere else. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on November 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the services should be covered. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 12, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental extraction (D7210) provided November 26, 2019.
You asked the Plan to pay for the dental extractions. You say that you received the denial and do not understand why the plan only paid $114 and not the 50% of the $554. You feel this should be covered for the number of teeth to be pulled. The Plan denied your request. The Plan says the maximum amount 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. The plan contract says that 2 extractions are allowed per year. The records show that the plan covered for a dental extraction on July 24, 2019. On this date of service, you had 2 extractions and the plan covered for one of the extractions. Therefore the third extraction is not covered. 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 dental extraction (D7210) provided November 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance transport provided on October 12, 2019.
You asked the Plan to waive the deductible for the ambulance transport. You say that the charge is excessive for the short distance. You say that this is not a fair charge. The Plan denied your request. The Plan says the deductible applied 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 your combined deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services. Ambulance transports are not excluded from the deductible. The item or service you asked the Plan to waive the copayment for falls within the "Ambulance services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your combined $500 deductible applies to ambulance transports. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on October 12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance transport provided on October 12, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care provided on September 5, 2019.
You asked the Plan to pay for the physician service. You say that you have not been paid according to the
Medicare allowable. The Plan denied your request. The Plan says the enrollee's claim would be covered under
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the
last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the initial hospital care provided on September 5, 2019.