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

We decided that the Plan does not have to pay for non-emergent ambulance services provided on July 24, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that the doctor determined you needed to be transferred by ambulance as it would be dangerous for you to travel in a wheelchair The Plan denied your request. The Plan says they have been in contact with EmergyCare who stated that there were appropriate facilities that were closerl. The Plan states they have also provided the Plan with a signed Advanced Beneficiary Notice of Noncoverage that was provided to you specifying that Medicare does not pay for transports for the convenience of a patient, family, or physician. The Plan states they also contacted the Hospital to inquire if there was a reason you were not eligible to go to a facility closer to the hospital and medical records were provided and there was nothing in the records that indicated you were not eligible to go to a closer facility.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. As it has been confirmed that there were facilities available that were closer. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on March 5, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that periodontal maintenance is a
preventive service and should be covered by your $150 allowance for preventive dental services. 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, periodontal maintenance is not a
covered preventive service under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance provided on March 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for reline complete maxillary denture (chairside) (D5730)
provided on November 12, 2019.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services
rendered. 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 reline complete maxillary denture
(chairside) (D5730) provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatment (98940) rendered by an out of network (OON) provider on January 6, 2020.
You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visit and x-rays provided on October 14, 2019.
You asked the Plan to waive the copayments for the urgent care visit and the x-rays. You say that you were sent these bills in error. 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 $30 copayment for office visits for members of the Health plan and a $45 copayment per encounter for x-rays for members of the Health plan or Part B only plans. You have been asked to pay a $30 copayment for the urgent care visit and a $45 copayment and the x-rays. The urgent care visit falls within the "Urgently needed services" benefit category. The x-rays fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayments for the urgent care visit and x-rays provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on August 8, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that you should be reimbursed because you got a cleaning. The Plan denied your request. The Plan says periodontal maintenance is not included in your dental benefit. The Plan also says this service is not considered a preventive dental 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 periodontal maintenance provided on August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on November 11, 2019.
You asked the Plan to waive the copayment for a laryngoscopy. You say that this cost should have been taken care of by your insurance company. The Plan denied your request. The Plan says the correct copayment has been 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 $100 copayment for outpatient surgery/Medicare Preferred HMO Prime Rx/outpatient procedures. You have been asked to pay a $100 copayment for a laryngoscopy. The procedure that was provided to you is considered an outpatient surgery; therefore, the correct copayment has been applied. A laryngoscopy falls within the outpatient surgery/Medicare Preferred HMO Prime Rx/outpatient procedures benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a laryngoscopy provided on November 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.
You asked the Plan to pre-approve physical therapy. You say that you need to continue the physical therapy you began in New York while you are in Florida. The Plan denied your request. The Plan says this can is not urgent and therefore is not covered.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The rules say that urgently needed services are those needed because of an unforeseen illness or condition. We looked at the file and Medicare rules. The record shows that the condition for which you are requesting these services is not unforeseen, and therefore not urgent. The record shows that you were being treated for this condition prior to traveling outside of the Plan's service area. Your contract with the Plan states that only emergent or urgent care is covered outside of the Plan's service area. Based on this information, we decided that Medicare rules for coverage of physical therapy. have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests and cone beam CT capture and interpretation provided on October 3, 2019.
You asked the Plan to pay for the pulp vitality tests and cone beam CT capture and interpretation. You say that you received a $300 bill and did not know what was wrong during the visit. The Plan denied your request. The Plan says these services are not covered preventive dental 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 because they are not preventive services. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests and cone beam CT capture and interpretation provided on October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on July 25, 2019 by an out-of-network provider.
You asked the Plan to waive the coinsurance for the laboratory services. You say that you went to an out-of-network provider are wanting the claims to be processed with your in-network benefits. The Plan denied your request. The Plan says you were seen by several out-of-network providers without requesting a transition of care exception prior to the services you received. The Plan states you also did not request prior approval for these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received laboratory services provided on July 25, 2019 by an out-of-network provider. You are asked to pay 40% coinsurance for the out-of-network laboratory services. You have out-of-network benefits and without a transition of care plan or an approved prior authorization for services, according to your 2019 EOC, you have a 40% cost share for out-of-network, outpatient diagnostic tests. 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 laboratory services provided on July 25, 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 resin-based composite provided on October 12, 2019.
You asked the Plan to pay for the resin-based composite. You say that the line on the bill that says "New
Patient Offer" for $150 was actually for a cleaning. 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 resinbased
composite provided on October 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 27, 2019 by an out of network (OON) provider.You asked the Plan to pay for the MRI. You say that you would like reconsideration as these services were medically necessary.The Plan denied your request. The Plan says this service was rendered out-of-network without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 December 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nerve injection.You asked the Plan to pre-approve the requested services. You say that the injection has been proposed to provide a longer period of reduced pain, and improved mobility.The Plan denied your request. The Plan says there is not enough evidence found to show the services are medically necessary for your condition.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 the requested services. Our physician reviewer found that you have chronic right knee pain due to osteoarthritis. You have tried physical therapy, oral medications, intra-articular steroid injections and visco supplementation. You had genicular nerve blocks performed, which gave you 3-4 weeks of pain relief. The requested service is an experimental/ investigational procedure that is the subject of ongoing clinical trials. You are not enrolled in a clinical trial. Therefore, the request is deemed not medically reasonable or 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 the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve a nerve injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supplementary benefits.
You asked the Plan to pre-approve the supplementary benefits. You say that you are requesting review of denial of services due to your illnesses. The Plan denied your request. The Plan says these service is not approved for coverage.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Allowance for healthy food purchases and/or electricity, water and/or phone bill payments (cash card) is not covered by traditional Medicare and it is not a benefit with the Plan. The Plan offers the benefit of a card for allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020 for enrollees that meet very specific criteria. For an enrollee to be a candidate for this benefit he/she needs to have one of the eligible chronic conditions documented in the EOC and require intensive care coordination, and must be at high risk of hospitalizations or adverse health outcomes. You do not meet any of these criteria and for this reason the benefit is denied. Therefore, we decided that the Plan does not have to pre-approve supplementary benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin growth removal procedure provided on January 8, 2020.You asked the Plan to waive the copayment for the skin growth removal procedure. You say that the provider only trimmed your toenails and you have never been billed this much before. 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 $360 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $360 copayment for the skin growth removal procedure.You have been asked to pay a $179.27 copayment for the skin growth removal procedure. The skin growth removal procedure falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed by the outpatient hospital. 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 skin growth removal procedure provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on October 22, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there were in-network provider available 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 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 lab tests provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99202, 99212), and the chiropractic
manipulative treatment (98940) provided by an out of network (OON) provide from July 9, 2019 to October 9, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says the services were provided by an out of network provider
without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We
found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan
does not have to pay for the office visits (99202, 99212) and the chiropractic manipulative treatment (98940)
provided by the out of network (OON) provider from July 9, 2019 to October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on August 15, 2019.
You asked the Plan to pay for the extraction. You say that you were told that this provider was in-network. You also say that you were told you would get a $150 allowance toward the extraction. The Plan denied your request. The Plan says this provider is not a participating provider with your 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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the extraction provided on August 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an EGD provided on October 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for an EGD. You say that it is the hospital's responsibility to obtained prior authorization, not the providers.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the provider and facility are one entity under 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 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 an EGD provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 21, 2020.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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on January 21, 2020.