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

We decided that the Plan does not have to pay for the maxillary interim partial denture provided on January 13, 2020.
You asked the Plan to pay for the maxillary interim partial denture. You say that the enrollee needed this procedure to keep up with his nourishment as well as his activities of daily living. You also say that the enrollee did everything right, checking that the provider was in network, and providing them with his insurance card. The Plan denied your request. The Plan says this service is not medically necessary because the service is not covered under Medicare. The Plan also says that the EOC does not provide a benefit for this service.
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 maxillary interim partial denture provided on January 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 physician's services provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5050) purchased March 6, 2020.
You asked the Plan to pay for the hearing aids. You say that you received a check for $999 which do not cover the cost, for a difference of $250. The Plan denied your request. The Plan says the claim has been processed correctly and an additional payment does not apply.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay 20% coinsurance for out-of-network covered services. for Hearing services. You have been asked the plan to pay $250. The cost of the hearing aids was $1,249.99 and the plan reimbursed $999.99. You have a 20% coinsurance for out of network covered services. ($1,249.99 x 20% = $250). The hearing aids falls within the Hearing services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5050) purchased March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on February 25, 2020.
You asked the Plan to pay for foot orthotics (L3000). You say that the Plan should pay this claim. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment for tooth #30 and an abutment supported porcelain/ceramic crown for tooth #30.
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that it is necessary for tooth #30 to be replaced because it is essential for chewing on the right side. You also say that you would like these services covered because the Plan would cover a replacement of the original cap on the tooth, which should be the same for the implant. The Plan denied your request. The Plan says these services are not a benefit for tooth #30. The Plan also says that tooth #30 is a posterior (back) tooth and does not qualify for implant benefits because implant benefits are limited to anterior (front) teeth.
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, implants and implant crowns that replace posterior (back) teeth are not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment for tooth #30 and an abutment supported porcelain/ceramic crown for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on March 19, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that this appointment was for the preventive services and everything you had done was for the preventive of your tooth. The Plan denied your request. The Plan says this 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 the periodontal maintenance provided on March 19, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (91784) provided on January 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 outpatient mental health services (91784) provided on January 30, 2020 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 limited oral exam (D0140), the panoramic x-ray (D0330), the extraction (D7140), the extraction (D7210), the incision and drainage of an abscess (D7510), the initial 15 minutes of general anesthesia (D9222) and an additional 15 minutes of general anesthesia (D9223) provided on December 20, 2019.
You asked the Plan to reimburse you for the dental services. You say that you were very sick with a fever and infection. You say that you were referred to this provider as there was no one else available. You also say that no one told you that your insurance would not cover anything until after the services were provided. The Plan denied your request. The Plan says the services that you received were dental in nature. The Plan says that dental services are not covered under your medical coverage.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you 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 reimburse you for the limited oral exam (D0140), the panoramic x-ray (D0330), the extraction (D7140), the extraction (D7210), the incision and drainage of an abscess (D7510), the initial 15 minutes of general anesthesia (D9222) and an additional 15 minutes of general anesthesia (D9223) provided on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided September 13, 2019 to September 27, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the copayment should be waived The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Inpatient Care. You have been asked to pay a $200 copayment for the inpatient hospital services. The inpatient hospital services fall within the Inpatient 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 inpatient hospital services provided September 13, 2019 to September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient wound care services provided from January 7, 2020 to January 28, 2020.
You asked the Plan to pay for the outpatient wound care services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be 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 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 outpatient wound care services provided from January 7, 2020 to January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an Inogen One G5 Portable Oxygen System.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that after you almost passed out your cardiologist recommend a portable oxygen concentrator so your bought one. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for an Inogen One G5 Portable Oxygen System purchased on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on December 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the automatic external defibrillator. You say that the company is the sole provider worldwide of the lifevest wearable defibrillator. You were informed that authorization is not required since the ordering physician and facility are both in-network. The Plan denied your request. The Plan says this request exceeds the number of authorized services. Enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 automatic external defibrillator (K0606) provided on December 22, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of an anesthetic or steroid provided on August 20, 2019 by an out of network provider.
You asked the Plan to pay for the injection. 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. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 13, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the injection of an anesthetic or steroid provided on August 20, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two removals of torus mandibularis (D7473 x2).
You asked the Plan to pre-approve the removals of torus mandibularis. You say that without this procedure you remain without teeth. You also say that you are unable to chew solids or eat a nutritious meal. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 the two removals of torus mandibularis (D7473 x2).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on September 12, 2019 to December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that the services should be covered. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.
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 psychotherapy services (90834) provided on September 12, 2019 to December 19, 2019 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 oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on February 11, 2020 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you were advised in January that the provider in this case was in network. You say that, as a result, you went to his office to receive the services. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says services that you receive out of network are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the oral exam, prophylaxis and x-ray are listed as covered services, they are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on February 11, 2020 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says
authorization is required for this service.
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
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 physician's services provided on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance provided on January 6, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that you have been seeing a periodontist for appointments since your perio surgery in 1982. You also say that you have had 4 cleaning appointments per year, which were covered before Medicare coverage came into effect. The Plan denied your request. The Plan says the dentist that provided this treatment is not part of the Plan's network. The Plan also says that services done by an OON dentist 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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance provided on January 6, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for urinary catheters (A4332, A4351) provided February 1, 2020 to March 1, 2020.
You asked the Plan to waive the coinsurance for the urinary catheters. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medical Supplies. You have been asked to pay a 20% coinsurance for the urinary catheters. The urinary catheters fall within the Medical Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for urinary catheters (A4332, A4351) provided February 1, 2020 to March 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on March 6, 2020.
You asked the Plan to pay for the dental services. You say that you did not realized that only certain x-rays were covered. You say that you were having problems with your dentures and went to have them looked at. You also say that you did not think you would be charged to have them figure out why your dentures were not snapping onto your implant. The Plan denied your request. The Plan says says the limited oral evaluation and panoramic x-ray are not 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. The record shows that the Plan confirmed with the provider in this case that they will write-off the denied charges for the panoramic x-ray, thus leaving you with no liability for this service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the panoramic x-ray (D0330) provided on March 6, 2020.