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

We decided that the Plan does not have to waive the coinsurance fora mastectomy (19307) provided from June 18, 2019 through June 22, 2019.You asked the Plan to waive the coinsurance fora mastectomy. You say that it was said that you were not admitted when you had surgery in an outpatient hospital. You say you were in the hospital for 24 hours.The Plan denied your request. The Plan says outpatient surgery has a 20% coinsurance.The Plan also says that the review of the call history shows that you did not contact the plan prior to the date of service in question to inquire about the cost-share related to this benefit.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 outpatient surgery. You have been asked to pay a 20% coinsurance for a mastectomy. This service falls within the outpatient surgery benefit category. The allowable Medicare amount of $4,537.09 x 20% = $907.42. 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 a mastectomy (19307) provided from June 18, 2019 through June 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (code D0140) and first intraoral periapical x-ray (code D0220) provided on August 29, 2019.You asked the Plan to pay for the problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you went to the plan website to determine what dentists in your area were in-network with your Plan. You also say that you believe you are entitled to one exam per year with x-rays.The Plan denied your request. The Plan says these services are not covered procedures under your benefit plan. The Plan also says that the rendering provider is out-of-network with 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 record shows that you received these services from an out-of-network provider, and your Plan does not provide covered benefits for services that are received out-of-network.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (code D0140) and first intraoral periapical x-ray (code D0220) provided on August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental extractions from an oral surgeon.
You asked the Plan to pre-approve the dental extractions from an oral surgeon. You say that you are in pain and a general dentist cannot perform the extractions because the tooth roots may break. The Plan denied your request. The Plan says the services being requested are not covered by Medicare or under the enrollee's contract
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 benefits are limited to services performed by an in-network general dentist. You are requesting coverage for services with an oral surgeon. Services with an oral surgeon are not covered under the Plan's dental benefits. Therefore, we decided that the Plan does not have to pre-approve dental extractions from an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intermittent urinary catheter, with insertion supplies (CPT Code A4353) provided on August 19, 2019.
You asked the Plan to waive the coinsurance for the intermittent urinary catheter. You say that you believe that the intermittent catheters should be covered as medical supplies not ostomy supplies as you have not had to pay a copay before 2019, all of the other supplies are covered as medical supplies so this one that is pulling a copay should be covered as medical as well. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). During the appeal process the Plan reviewed your claim history as well as your Plan benefits. The Plan year runs from January 1 through December 31 each year. In 2017 your EOC states that Ostomy supplies are covered with no member cost share. Starting January 1, 2018, the benefit changed to a 20% coinsurance for Ostomy supplies. This was reflected in your EOC for 2018 and 2019. The cost share is a contractual obligation that you agreed to upon enrolling with the Plan. A4353 (Intermittenturinary catheter, with insertion supplies) meets the definition of Ostomy supply and is categorized as an ostomy supply by Medicare. Therefore, you will remain liable for the 20% Ostomy coinsurance totaling $100.00 to the Provider on August 19, 2019. 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 intermittent urinary catheter, with insertion supplies (CPT Code A4353) provided on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye and medical examination for diagnosis and treatment (92014, 02025, 02781) provided on September 20, 2019 to September 22, 2019 by an out of network (OON) provider.You asked the Plan to pay for an eye and medical examination for diagnosis and treatment. You called the plan and were told you had out-of-network benefits. You would like these claims paid, based on that information. The Plan denied your request. The Plan says that you must use a provider who is contracted with their vision network. Care rendered by a provider that is not part of their vision dental network 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 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 looked through the record and could not find the call you referenced.Your contract with the Plan states that you do not have out-of-network benefits.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 foran eye and medical examination for diagnosis and treatment (92014, 02025, 02781) provided on September 20, 2019 to September 22, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Magnetic Resonance Angiography (MRA) of the Head (70546) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the MRA of the Head. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers available who can render the services at issue. Authorization has already been provided to receive the service at a contracted provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the Magnetic Resonance Angiography (MRA) of the Head (70546) to be provided an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for bridgework provided from May 31, 2017 to July 3, 2019.You asked the Plan to pay for the bridge-work. You say that physician is a contract provider with the Plan and that he gave you an excellent prognosis before the procedure, but provided you with poor service. You say that the Plan recommended this provider and you should get a refund.The Plan denied your request. The Plan says that the bridge in dispute has a poor prognosis due to the enrollee's compromised periodontal status to support a long eight units span bridge. The Plan says that, because of the poor prognosis, the bridge does not qualify as a benefit. The Plan also says that, based on the Evidence of Coverage, the plan covers up to $1,800, so the plan will cover this amount minus the already paid $202 resulting in reimbursement of $1,598.The Plan must follow Medicare rules. For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. The rules also 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided any evidence that there is a $1,800 limit to their coverage of dental benefits for the dates of service in dispute. The Plan did not provide an Evidence of Coverage for the 2018 and 2019 calendar years. The Plan's denial reason states that the services in dispute were non-covered because of the poor prognosis. However, the enrollee saw a participating dentist and would not be responsible for knowing that the bridge had a poor prognosis. There is no evidence that the enrollee was clearly advised by the participating provider of which services would or would not be covered. We are unable to verify, based on the information provided to us, that the enrollee had any clear notification of non-coverage through the Plan or their participating provider, who is considered an agent of the Plan. The information provided to us by the Plan does not show that the services are non-covered, that there was clear notification of non-coverage, or that there is a limit of $1,800 for coverage of dental benefits. Therefore,the Plan's partial denial reason has not been substantiated.Therefore, we decided that the Plan has to pay for bridgework provided from May 31, 2017 to July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with a specialist (99213) to be provided by the out of network provider.
You asked the Plan to pre-approve an office visit. You say that it is the kind of medication that provider is willing to administer to your father. You state that the Plan does not carry this medication in their pharmacy. You say that he was supposed to have a sample shot in network, and it was taken away when the Chief of Orthopedics advised him that it is not in the Plan's policy to administer this medication. You state that it is not possible to have this medication administered by an in-network provider due to the lack of expertise and lack of willingness from the Plan. The Plan denied your request. The Plan says they denied the medical services because the physician is not part of the Plan's referral circle and is not uniquely qualified to treat your father's knee pain. The Plan also says there was no evidence that seeing a provider within the referral circle would be detrimental to your health or that it is medically necessary for him to see a provider outside of the referral circle.
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 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. 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 an office visit with a specialist (99213) to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shower equipment purchased on May 29, 2019.
You asked the Plan to pay for the shower equipment. You say that the enrollee should not have pay for this equipment out of pocket when it is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules state that for equipment to be covered, it must primarily serve a medical purpose. The enrollee's contract states that in order for any services to be covered, they must be medical services rendered by a provider. Unfortunately, the Store is not considered a provider and while a bathroom modification to include a walk-in shower may be beneficial to the enrollee, it is not a covered service with Medicare nor the Plan. Therefore, we decided that the Plan does not have to pay for shower equipment purchased on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxilla facial surgery with dental implants.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered, and it appears to be cosmetic in nature.
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 the services when the services are medically necessary and reasonable. 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 reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the damage to the teeth was the result of decay/neglect over time and not from trauma from an external force, which could be a covered service under the medical plan whereas neglect would not be. The oral surgery procedures to remove the affected teeth would be considered medically necessary under the policy, however the placement of implants and subsequent crown or bridge restoration on such implants would not be. After removal of the affected teeth, tooth replacement is possible by way of removable partial dentures. The requested treatment is a reasonable alternative treatment plan, however there is no coverage for implant restoration under the Plan. Given the contractual limitations, and the availability of alternative treatments, there is no medical necessity for the proposed implant treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve maxilla facial surgery with dental implants.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for chiropractic services provided on August 20, 2019 through October 17, 2019.
You asked the Plan to hold you harmless for the chiropractic services. You say that you would like reconsideration as you have a referral for these services. The Plan denied your request. The Plan says that the referral for chiropractic care had been for only 6 visits.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the chiropractic services by the facility. The facility is a contract provider. The file does not show that the Plan provided notice that the chiropractic services would not be covered. Under Medicare rules, this means the chiropractic services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for chiropractic services provided on August 20, 2019 through October 17, 2019.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on August 23, 2019.
You asked the Plan to waive the copayment for emergency room visit. You say that according to the enrollee's insurance card, the copayment for emergency room in 2019 was only $80 per visit. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $90 copayment for emergency room visit. The enrollee has been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on August 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (36415, 80048,
81001, 81002) provided December 13, 2018.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that you had two visits
in the same day and the copayment from the first visit should be waived. The Plan denied your request. The
Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay an $80
copay for Emergency Care.
You have been asked to pay an $80 copay for the Emergency Room Services. The Emergency Room Services
fall 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
Emergency Room Services (36415, 80048, 81001, 81002) provided December 13, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90837, 90785, 90791) provided October 30 to November 26, 2019.You asked the Plan to pay for the outpatient mental health services. You say that your Primary Care Physician would not provide a referral as the plan requested, and the services at issue were medically necessary.The Plan denied your request. The Plan says records show you have primary insurance through another carrier. The claims must be submitted to your primary insurer before the plan can consider them.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has advised to submit the claims to the primary insurer and then provide the plan with a copy of the Explanation of Benefits issued by the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the outpatient mental health services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90837, 90785, 90791) provided October 30 to November 26, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on April 11, 2019.You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you do not understand why the plan has not paid the balance. You say you do not know why you owe $265 when you met your deductible. The Plan denied your request. The Plan says 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 $265 copayment for Medicare-covered outpatient surgery at an in-network ambulatory surgical center. You have been asked to pay a $265 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you do not have a deductible with this plan.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 the upper GI endoscopy provided by on April 11, 2019.