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

We decided that the Plan does not have to pay for the bite wings, first intraoral periapical x-ray, and two additional intraoral periapical x-rays provided.

You asked the Plan to pay for the bite wings and intraoral periapical x-rays. You say that you did not ask for these procedures to be performed.The Plan denied your request. The Plan says benefits for these services had been satisfied and the frequency limitations had been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, bite wing x-rays and intraoral x-rays are each limited to once per calendar year. The record shows that you received a bite wing x-ray and a first intraoral periapical x-ray, and your bite wing x-rays and intraoral x-rays benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe bite wings, first intraoral periapical x-ray, and two additional intraoral periapical x-rays provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive medicine evaluation (99397) provided on September 2, 2020, by an out-of-network (OON) provider.You asked the Plan to pay foran OON preventive medicine evaluation. You say that you needed this service because your PCP was not taking appointments.The Plan denied your request. The Plan says this service was not authorized.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 had network providers available who could have provided 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 forthe preventive medicine evaluation (99397) provided on September 2, 2020, by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the topical application of fluoride (D1208) provided on August 25, 2020.You asked the Plan to pay forthe dental services. You say that there should be a one-time exception made for these services. You say that it is not apparent from the Medical Plan guide that you should be responsible for the costs. You also say that had you known this could occur, you would have changed to an in network provider.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that the out of network liability was applied correctly. The Plan also says out of network providers may still bill you for any amount greater than the MAC payment made by the plan to the 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, out of network providers may still bill you for any amount greater than the MAC payment made by the plan to the provider.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120), prophylaxis (D1110), and the topical application of fluoride (D1208) provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation feature (E2300).You asked the Plan to pre-approvea power seat elevation feature. You say that this is necessary for you.The Plan denied your request. The Plan says that this is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approvea power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 3, 2020, by an
OON provider.
You asked the Plan to pay for nursing facility care. You say that it is the legal responsibility of the insurer to
pay medical claims for medically necessary procedures. The Plan denied your request. The Plan says rules for
payment have not been met.
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 had network providers
available who could have provided 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 August 3, 2020,
by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 extractions (D7140) provided on June 30, 2020.
You asked the Plan to pay for the dental services. You say that your 3 tooth bridge broke. You say that your regular dentist was closed so you went to the hospital. You say that you had 2 tooth nubs removed and were fitted for a partial. You also say that the claims have all denied. The Plan denied your request. The Plan says extractions are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2 extractions (D7140) provided on June 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Ambulance Service on April 5, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 5, 2020. The ambulance benefit is a transportation benefit.When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by THE Ambulance Service on April 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee. You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee
is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that there is no way to obtain a prior authorization when the provider does not know who they will be treating until the day of.The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered to the enrollee.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 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 forthe medical services provided on January 22, 2020 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 periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on February 4, 2020.
You asked the Plan to pay for the dental services. You say that you were still covered under the Plan until February 29, 2020. You also say that the services should be covered. The Plan denied your request. The Plan says dental services are not covered in 2020. The Plan says that dental coverage ended on December 31, 2019.
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 periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0274) provided on February 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided fromAugust 1, 2020, to August 8, 2020.You asked the Plan to waive the copayment forSNF care. You say that you had to stay at this facility because you had COVID, and no other facilities would accept you.The Plan denied your request. The Plan says the copayment amount you are 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). Your contract with the Plan clearly says that you must pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care.You have been asked to pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forSNF care provided from August 1, 2020, to August 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on February 27, 2020, to March 23, 2020.You asked the Planto waive the copayment for physical therapy. You say that you paid every week. You say that you do not owe an additional $45. 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 $40 copayment for outpatient rehabilitation service. You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked to pay is $360 ($40 x 9 visits = $360). Physical therapy falls within the outpatient rehabilitation service 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 physical therapy provided by a participating provider on February 27, 2020, to March 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided on July 21, 2020, through July 24, 2020.You asked the Plan to waive the copayment forinpatient hospital care. You say that the services should be covered.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 copayment per day for each day one to five for inpatient hospital services. You have been asked to pay a $375 copayment per day for each day one to five for inpatient hospital care. This service falls within the inpatient hospital services benefit category. This means that you have beenasked to pay the correct amount based on your contract with the Plan ($375 x 3 = $1,125). 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 forinpatient hospital care provided on July 21, 2020, through July 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and waive the out of
network cost share for the periapical x-ray (D0220) provided on June 11, 2020.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied
your request. The Plan says the provider in this case is out of network. The Plan says that out of network
providers can bill you for any amount greater than the MAC payment made by the plan to the provider. The
Plan says that 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit for
this service has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, services that you receive out of
network are subject to higher cost shares. The Plan paid 100% of the allowable amount. Out of network
providers can bill you for any amount greater than the MAC payment made by the plan to the provider. Cost
share is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally,
the frequency limit for the oral exam has been exceeded. The record shows that the Plan paid for a limited oral
evaluation that you received on March 25, 2020. Therefore, we decided that the Plan does not have to pay for
the limited oral evaluation (D0140) and waive the out of network cost share for the periapical x-ray (D0220)
provided on June 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvepulsed low-grade thermal ablation of the facet joint nerves.You asked the Planto pre-approvethe pulsed low-grade thermal ablation procedure. You say that it is felt that this should be covered because you had good relief from the prior injections.The Plandenied your request. The Plansaysthe specific type of nerve ablation being requested in this case is not covered by Medicare. A standard non-pulsed thermal ablation could be covered if requested.The Plan must follow Medicare rules. Medicare rules say that non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered.Therefore, we decided that the Plandoes not haveto pre-approvepulsed low-grade thermal ablation of the facet joint nerves
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the cone beam CT (D0634), the unspecified preventive service (D1999 x 2), the surgical placement of an endosteal implant (D6010), and the nitrous oxide (D9230) provided from June 11, 2020, to July 30, 2020.
You asked the Plan to pay the in network rate for the dental services. You say that insurance should pay more than the $741.50 that was paid for the services you received on July 30, 2020. You say that out of network providers are being treated as in network providers due to the pandemic. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that there is a 50% coinsurance for dental services that you receive out of network. The Plan also says that out of network dental providers may bill you for any charges remaining over the allowed amount for all dental 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 cone beam CT and unspecified preventive service are not among those covered under this benefit. Additionally, the Evidence of Coverage clearly states that out of network dental providers may bill you for any charges remaining over the allowed amount for all dental covered services. The record shows that the Plan paid the allowed amount for the services that you received. Therefore, we decided that the Plan does not have to pay the in network rate for the cone beam CT (D0634), the unspecified preventive service (D1999 x 2), the surgical placement of an endosteal implant (D6010), and the nitrous oxide (D9230) provided from June 11, 2020, to July 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve9 additional physical therapy services.You asked the Plan to pre-approveadditional physical therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or toprevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had extensive therapy and the documentation does not indicate that the enrollee's functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has had instruction in a home exercise program. The requested services are not part of a maintenance program, and  the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy services have not been met.Therefore, we decided that the Plan does not have to pre-approve9 additional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreye exam with refraction (92014 and 90215) provided on July 21, 2020.You asked the Plan to pay foreye exam with refraction. You say that the service should be covered.The Plan denied your request. The Plan says you have exceeded the $75 maximum allowance for this service.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 covers these services when one routine eye exam with refraction per year with a $75 allowance.We looked at the file and the Plan's rules. You have exceeded the Plan's maximum allowance for this service and are responsible for the difference.  Based on this information, we decided that the Plan's rules for coverage of eye exam with refraction have not been met.Therefore, we decided that the Plan does not have to pay foreye exam with refraction (92014 and 90215) provided on July 21, 2020.