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

We decided that the Plan does not have to pay for the endosteal implant and extraction provided on October 29, 2020.
You asked the Plan to pay for the endosteal implant and extraction. You say that you were not advised that the treating provider did not accept Medicare. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective December 4, 2019, to December 4, 2021. The Plan also says that services performed by a privately contracted provider 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 among those covered when they are received by a provider who has opted out of Original Medicare. The record shows that you signed a financial agreement that advised you that this practice has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the endosteal implant and extraction provided on October 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided from October 26, 2020 to November 23, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided from October 26, 2020 to November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 28, 2020. You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance. 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 physician's services. 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 September 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on October 21, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that the doctor ordered the colonoscopy and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You have been asked to pay a $350 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy 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 for a diagnostic colonoscopy provided on October 21, 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.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the admission criteria for ongoing medical care at the LTACH level. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.
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. Our physician reviewer found there is no documentation provided necessitating admission to an LTACH. 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 she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical nutrition therapy. You asked the Plan to pre-approve these services. You say that you need to lose weight. The Plan denied your request. The Plan says you do not meet the criteria for coverage. The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pre-approve medical nutrition therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Travatan Z Dro 0.004%. You asked the Plan to pre-approve Travatan Z Dro 0.004%. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Travatan Z Dro 0.004%. Benefits for Travatan Z Dro 0.004% may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on December 15, 2020.
You asked the Plan to pay for the dental services. You say that you have been on Medicare for 5 years. You say that you have always had your teeth cleaned 2 times per year and had no problems. You say that you were not aware of only having 1 cleaning per year. You also say that you are on a limited income and need help with this bill. The Plan denied your request. The Plan says that 1 oral exam and 1 cleaning are covered per year. The Plan also says that the frequency limit for these services have been exceeded.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Plan's claim that the frequency limit for these services have been exceeded was not substantiated. There is no documentation which shows that the enrollee received these services earlier in the calendar year. Without documentation to support the Plan's decision, we are not able to determine if the services were previously paid. Therefore, we decided that the Plan has to pay for the oral exam (D0120) and prophylaxis (D1110) provided on December 15, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from June 1, 2020, to June 26, 2020.
You asked the Plan to waive the copayment for SNF care. You say that when you contacted the Plan you were told that the enrollee would not have any cost-share for the SNF stay. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct. The Plan also says that you were not advised that the enrollee would not be charged a cost-share for SNF care.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1 to 10, a $20 copayment per day for days 11 to 20, and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. The enrollee's previous SNF care in May 2020 applied 7 days to the SNF benefit period. This stay from June 1, 2020, to June 26, 2020 lasted 25 days, which are days 8 to 32 of the benefit period, resulting in a copayment amount of $2,336. The enrollee has been asked to pay a $0 copayment per day for days 1 to 10, a $20 copayment per day for days 11 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 the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the SNF care provided from June 1, 2020, to June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0140), intraoral radiographic imaging (D0220) and unspecified preventative procedure (D1999) provided on September 16, 2020.
You asked the Plan to pay for the dental services. You say that this was a necessary service, and this provider is in the Plan's network. The Plan denied your request. The Plan says Medicare does not cover most dental care, and the services provided are also not covered by the Plan's supplemental dental 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 oral evaluation (D0140), intraoral radiographic imaging (D0220) and unspecified preventative procedure (D1999) provided on September 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia, 60 mg/ml subcutaneous solution. You asked the Plan to pre approve Prolia. You say that the enrollee has been using Prolia for osteoporosis management for 3 years and has demonstrated improvement to her bone density with this. The Plan denied your request. The Plan says the requested drug is dispensed by the specialty pharmacy. The Plan also says that drugs that are requested through the pharmacy are covered by the pharmacy benefit, or Medicare Part D. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prolia, 60 mg/ml subcutaneous solution. Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for confusion, chest pain, and shortness of breath. The enrollee's medical problems are stable. The documentation does not support any complex nursing or rehabilitation needs. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, above knee, flexible
protective outer surface covering system (L5964)
You asked the Plan to pre-approve the extra protective cover. You say that you request the plan review the
documentation based on their own policy and the enrollee's specific need for an advanced knee and foot to
allow him to return to being independent and an active individual. The Plan denied your request. The Plan says
the enrollee does not meet the criteria for an extra protective cover and the extra covering is not routinely
necessary.
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 extra protective cover. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the records support the replacement of his existing dysfunctional prosthetic.
However, the endoskeleton was not sufficiently justified in the records. The enrollee should be able to
effectively ambulate safely without the need for the endoskeleton based on the clinical assessments. Therefore,
this request for such will be considered not 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 the extra protective cover have not been met. Therefore, we decided that the
Plan does not have to pre-approve addition, endoskeletal system, above knee, flexible protective outer surface
covering system (L5964)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing rendered on September 9, 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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that the CxBladder testing is non-covered.
We looked at the file and Medicare rules. The test at issue is CxBladder. This test is not covered by Medicare.
Therefore, we decided that the Plan does not have to pay for the CxBladder testing rendered on September 9,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0120), intraoral radiographic imaging (D0220, D0230) and bitewing images (D0274) provided on January 27, 2020, by an out-of-network (OON) provider. You asked the Plan to pay for the dental services. You say that the Plan should make an exception in this case due to transitional obstacles outside of the provider's control. The Plan denied your request. The Plan says they do not cover out of network services under their supplemental dental 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 oral evaluation (D0120), intraoral radiographic imaging (D0220, D0230) and bitewing images (D0274) provided on January 27, 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 gingival irrigation (D4921 x 2), the localized delivery of antimicrobial agents via a controlled release vehicle (D4381 x 2), and the drugs or medicaments (D9630) provided on December 21, 2020.
You asked the Plan to pay for the dental services. You say that you feel that the denied codes are part of the code D4342 for scaling and root planing. You also say that you feel the services should be covered based on what you pay for a premium. The Plan denied your request. The Plan says the services you received are not listed as covered services. The Plan also says that medications and supplies are excluded from coverage.
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 gingival irrigation (D4921 x 2), the localized delivery of antimicrobial agents via a controlled release vehicle (D4381 x 2), and the drugs or medicaments (D9630) provided on December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for X-rays provided on November 11, 2020.
You asked the Plan to waive the copayments for X-rays. You say that you feel that you should only owe one copayment and not per each X-ray. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $20 copayment for each X-ray. You received 4 X-rays on November 11, 2020. Therefore, you are responsible to pay a $20 copayment per each X-ray. The total amount you owe is: $20 (copayment) x 4 (X-ray's) = $80. You have been asked to pay the total copayment amount of $80 for X-rays. 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 X-rays provided on November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the remainder of the bill for the dental services. You asked the Plan to pay for the dental services. You say that cleanings are part of your covered benefit. The Plan denied your request. The Plan says you reached the $1,000 annual allowance limit in this claim, therefore you are responsible for a portion of the bill. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The plan has a $1,000 annual allowance for Non-Medicare covered dental services. The Plan has provided evidence that you reached this $1,000 annual limit in the disputed claim. The Plan's responsibility is $37 and your responsibility is $22. Therefore, we decided that the Plan does not have to pay for the remainder of the bill for the dental services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the home health services provided from August 24, 2020, to August 27, 2020.
You asked the Plan to waive the cost shares for the services provided. You say that you were told by the therapists you would not be charged. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible. The provided services within the benefit category home health services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible. This cost sharing is a contractual obligation that had not been met at the time the services provided was received on August 24, 2020 to August 27, 2020. The cost sharing amount is not determined by the quality of care or the outcome of services. Therefore, we decided that the Plan does not have to waive the cost shares for the home health services provided from August 24, 2020, to August 27, 2020.