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

We decided that the Plan does not have to waive the copayments for the airway examination with an endoscope and a biopsy provided on July 11, 2019 and July 26, 2019.
You asked the Plan to waive the copayments for the airway examination with an endoscope and the biopsy. You say that you do not think you should pay for the biopsy surgery because they did not do it correctly the first time. 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 $225 copayment for the surgical visit for Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center. You have been asked to pay a $225 copayment for the airway examination with an endoscope and a $225 copayment for the biopsy. The airway examination with an endoscope and the biopsy falls 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 the examination of airways with an endoscope or the biopsy provided on July 11, 2019 and July 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 18, 2019 by an out-of-network provider.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services performed were due to a medical reason.
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 eye refraction service provided on February 18, 2019 is not a covered benefit since it was performed for a medical reason of Vitreous degeneration on your left eye. Eye refractions are only covered by your plan if performed by a participating provider and performed as a routine screening per your EOC. Furthermore, since the supplemental benefits do not apply you also received the medical services from an out-of-network provider and you do not have out-of-network benefits. 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 services provided on February 18, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 27, 2020 by an outof-
network provider.
You asked the Plan to pay for the dental services. You say that you called the Plan and were advised the
provider was in-network. The Plan denied your request. The Plan says they verified that you were never
advised by the supplemental dental plan or your medical plan that the provider was in-network.
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.
Services provided by an out-of-network or non-contracted provider are not provided under this benefit
program. Therefore, we decided that the Plan does not have to pay for the dental services provided on February
27, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the miscellaneous dental service and two periodontal
maintenance services provided from March 20, 2019 to October 26, 2019.
You asked the Plan to pay for the miscellaneous dental service and periodontal maintenance services. You say
that you paid out of pocket for these dental services. The Plan denied your request. The Plan says these services
are not covered benefits.
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
miscellaneous dental service and two periodontal maintenance services provided from March 20, 2019 to
October 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pontic - porcelain/ceramic (D6245) and retainer crown -
porcelain/ceramic (D6740) provided from February 4, 2020 through February 13, 2020.
You asked the Plan to pay for the dental services. You say that the services were medically necessary and were
covered last year. 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,
they are not covered. Therefore, we decided that the Plan does not have to pay for pontic - porcelain/ceramic
(D6245) and retainer crown - porcelain/ceramic (D6740) provided from February 4, 2020 through February 13,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 8, 2020 by a nonparticipating
provider.
You asked the Plan to pay for the dental services. You say that the dentist is in-network. The Plan denied your
request. The Plan says the dentist does not participate with the supplemental 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.
The provider is not in-network and your EOC clearly states, services performed by a non-participating dentist
will not be covered. Therefore, we decided that the Plan does not have to pay for the dental services provided
on January 8, 2020 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313),
and an electrical connection (E2311).
You asked the Plan to pre-approve an expandable controller, a harness, and an electrical connection. You say
that this should be covered. The Plan denied your request. The Plan says the requested items are not medically
necessary to control the three approved power options through the joystick.
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 an expandable controller, a harness, and
an electrical connection. Our reviewer says that the requested items are not considered medically reasonable
and necessary in this case. Our physician reviewer found based on the available records, you do not meet
criteria for coverage for the requested items as your right upper extremity strength is adequate to control and
operate the power wheelchair.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller, a harness, and an electrical connection have not been
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), a
harness (E2313), and an electrical connection (E2311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical dental x-rays (D0220, D0230) provided
January 14, 2020.
You asked the Plan to pay for the dental x-rays. You say that the service should be covered. The Plan denied
your request. The Plan says this type of dental x-ray 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 intraoral
periapical dental x-rays (D0220, D0230) provided January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lens per lens, nonstandard lens and vision supply, accessory provided on March 26, 2019.
You asked the Plan to pay for these services. You say that this was more expensive at a plan provider. The Plan denied your request. The Plan says that these services are not covered by the Plan.
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 says vision service are covered when you go to a network provider. We looked at the file and the Plan's rules. The file indicates you did not go to a network provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the progressive lens per lens, nonstandard lens and vision supply, accessory provided on March 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99203) to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve an OON office visit. You say that the enrollee should stay under the care of
the doctors he has been seeing. The Plan denied your request. The Plan says the requested service is available
in-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 provider at issue in this case is not a network provider with the Plan. 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 an OON office visit. Our reviewer says that it is not medically necessary for
the enrollee to receive this service out-of-network. Our physician reviewer found this patient with a small
bowel neuroendocrine tumor has progression after surgical resection and sandostatin. His OON oncologist is
requesting referral to an OON neuroendocrine specialist to help streamline his care and is more convenient for
the patient. A neuroendocrine specialist is available within his network. Therefore, referral to an out of network
provider is not reasonable or 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 an OON office visit. have not been met.
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 an OON office visit.. Therefore, we decided that the
Plan does not have to pre-approve an office visit (99203) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the complete upper denture (D5110) and the
complete lower denture (D5120) provided on October 16, 2019 by out of network dentist.
You asked the Plan to reimburse you for the dental items. You say that you called the Plan multiple times to
make sure that dentures were a covered service. You say that you were advised that dentures were a covered
service and could send the receipt to the Plan for reimbursement. You say that you were advised after you
received the dentures that the provider was out of network and not covered. You also say that you were
misinformed by the Plan as this was the first time a network provider had been mentioned. The Plan denied
your request. The Plan says dental services are limited to those that are provided by in network providers only.
The Plan says that the provider in this case is not an in network provider.
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 and dentures are a covered service, they
are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to
reimburse you for the complete upper denture (D5110) and the complete lower denture (D5120) provided on
October 16, 2019 by out of network dentist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided to the enrollee on December 12,
2019 by a provider not enrolled in Medicare.
You asked the Plan to pay for the dental services. You say that the provider never opted out of Medicare. The
Plan denied your request. The Plan says the supplemental dental plan is unable to make payment for services
provided by a dentist that has opted out of Medicare.
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 provider is not enrolled in
Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided to the
enrollee on December 12, 2019 by a provider not enrolled in Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient
(D0150) provided on February 20, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were aware that the other codes billed on
the date of service would not be approved but you were under the impression code D0150 was covered. The
Plan denied your request. The Plan says the service is 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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation -
new or established patient (D0150) provided on February 20, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, x-ray, five extractions,
and full mouth debridement provided on October 30, 2019 and October 31, 2019.
You asked the Plan to pay for the comprehensive oral evaluation, x-ray, extractions, and full mouth
debridement. You say that though pre-authorization was needed before getting dental treatment, time was of
the essence. You also say that you needed to be in good dental condition in order for your transplant to be done.
The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral
evaluation, x-ray, five extractions, and full mouth debridement provided on October 30, 2019 and October 31,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the L300 System GO Plus Kit Neurostimulation device.
You asked the Plan to pay for the neurostimulation device. You say that you would like reconsideration
because this service is medically necessary for the treatment of the member's condition. The Plan denied your
request. The Plan says this device is not covered by Medicare for the member's condition.
The Plan must follow Medicare rules. Medicare rules say that the use of electric nerve stimulation in the
treatment of motor function disorders, such as multiple sclerosis, is a recent innovation, and the medical
effectiveness of such therapy has not been verified by scientifically controlled studies.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the neurostimulation device have not been met. Specifically, this device is not covered by
Medicare for the member's condition. Therefore, we decided that the Plan does not have to pay for the L300
System GO Plus Kit Neurostimulation device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the secondary cataract surgery provided on November 26, 2019.
You asked the Plan to waive the copayment for the secondary cataract surgery. You say that you should not be responsible for the copayment because it is the same eye you had the cataract surgery on. You say you are on a fixed income. 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 $250 copayment for each visit Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the secondary cataract surgery.
You have been asked to pay a $243.09copayment for the secondary cataract surgery. The secondary cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show this was a separate procedure than the original cataract surgery.
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 secondary cataract surgery provided on November 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 200 routine transportation trips.
You asked the Plan to pre-approve the additional routine transportation trips. You say that you would like
reconsideration because you require these trips to get to dialysis appointments and paying out-of-pocket will
cause financial hardship. The Plan denied your request. The Plan says your benefit only allows 30 trips for this
service.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 30 one-way trips per calendar year trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve an additional 200 routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment provided by the partial mastectomy provided on January 7, 2020.
You asked the Plan to waive the copayment provided by the partial mastectomy. You say that you should not be responsible for this copayment for a partial mastectomy because the surgeon was re-doing the original procedure. 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 $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for the partial mastectomy. The partial mastectomy falls 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 copayment provided by a partial mastectomy provided on January 7, 2020.
Your complaint that the surgeon should have taken out all the bad tissue the first time 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 26, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the psychotherapy services (99354, 99337 and G8427). You say that you would
like reconsideration as these services were medically necessary. The Plan denied your request. The Plan says
out-of-network services are covered when they are urgently needed or emergent or not available in-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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on June 26, 2019 by
an out of network (OON) provider.