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

We decided that the Plan has to pay for the prophylaxis and oral evaluation provided on February 20, 2020. 
 
You asked the Plan to pay for the prophylaxis and oral evaluation. You say that you were advised cleanings would be covered twice per year. The Plan denied your request. The Plan says that the services are only allowed once every 12 months. 
 
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.  
 
We looked at the Evidence of Coverage, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the prophylaxis and oral evaluation have been met. The Evidence of Coverage clearly says that up to two oral exams and 2 cleanings are covered every 12 months. Therefore, we decided that the Plan has to pay for the prophylaxis and oral evaluation provided on February 20, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided by the out of network (OON) provider on October 14, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided by the out of network (OON) provider on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids purchased on November 19, 2019 by an out-of-network provider.You asked the Plan to pay forthe hearing aids. You say that you were not informed about network providers.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 forthe hearing aids purchased on November 19, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) provided on February 11, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit because you had this service performed on January 25, 2018. Your EOC states, exams - Frequency/Limitations (Comprehensive oral evaluation) - One (1) procedure every three (3) years. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) provided on February 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from February 28, 2020 to March 3, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that the enrollee was discharged from hospice on February 28, 2020, and was then admitted for aggressive treatment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from February 28, 2020 to March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) provided on March 11, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. The Plan states you signed a treatment plan on October 14, 2019 acknowledging $0 plan payment and accepting responsibility for the cost of the 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. 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 crown - porcelain/ceramic (D2740) provided on March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forportable oxygen concentrator (E1392) oxygen accessory, battery pack/cartridge for portable concentrator (E1356) and sales tax (S9999) purchased February 28, 2018.You asked the Plan to pay forthe oxygen supplies. You say that you were told at the time of purchase that the insurance would not pay but now you see on TV all the time that Medicare would help.The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.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. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forportable oxygen concentrator (E1392) oxygen accessory, battery pack/cartridge for portable concentrator (E1356) and sales tax (S9999) purchased February 28, 2018
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services 
 
You asked the Plan to pre-approve home health nursing. You say that the enrollee needs continued education and diabetic assessments. The Plan denied your request. The Plan says the enrollee is medically stable and does not require nursing visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health nursing. Our physician reviewer found that the records do not show that skilled nursing services are required to effectively provide treatment, or services in order to improve the enrollee's condition, or to establish a maintenance program to maintain her condition, or prevent deterioration. The enrollee has chronic medical conditions. She has been educated on her disease management. She can follow up with her physician for diabetic management and does not need ongoing home health Skilled profession nurse visits for her condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health nursing have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that you have been in pain for over a year. The Plan denied your request. The Plan says necessary care is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested 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. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on February 13, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were not informed that the x-rays that were taken during the service were not covered. The Plan denied your request. The Plan says the service is not a covered benefit under the plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) provided on February 13, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe allergen immunotherapy injection provided on February 20, 2020.You asked the Plan to waive the copayment forthe allergen immunotherapy injection. You say that you were told there would be no copayment for the services. 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 $20 copayment per visit to a specialist. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the allergen immunotherapy injection.You have been asked to pay a $10.36 copayment for the allergen immunotherapy injection. The allergen immunotherapyinjection falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the allergen immunotherapy injection is considered a physician service.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 forthe allergen immunotherapy injection provided on February 20, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (CPT Code 92012) provided to the enrollee on January 28, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says there is not a referring provider listed. The Plan states the services were rendered at a non-participating facility and the Plan did not authorize any services for the provider.
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 ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (CPT Code 92012) provided to the enrollee on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the mandibular partial denture. We decided that the Plan does not have to pay for the gingival irrigation and oral surgery procedure.
You asked the Plan to pay for the mandibular partial denture, gingival irrigation, and oral surgery procedure. You say that Plan representatives indicated that this provider was in-network, and never advised that you needed pre-authorization. You also say that you received an extraction, and your lower partial denture was
worn and unfit. The Plan says that prior authorization was not obtained for the mandibular partial denture, which was required. The Plan also says that the gingival irrigation and oral surgery procedure are not covered benefits.
We decided that the Plan has to pay for the mandibular partial denture.
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 covers the mandibular partial denture when the services are medically necessary and reasonable. 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 pay for the mandibular partial denture. Our reviewer says that the service was medically necessary. Our physician reviewer found although pre-authorization for a mandibular removable partial was not obtained, the criteria for coverage for a new partial have been met. The old partial was greater than 10 years old and not serviceable. Our reviewer also found that the replacement of multiple missing mandibular teeth for adequate masticatory function was medically reasonable and 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 mandibular partial denture have been met. Therefore, we decided that the Plan has to pay for the mandibular partial denture.
We also decided that the Plan does not have to pay for the gingival irrigation and oral surgery procedure.
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) and oral surgery procedure (D7999) provided on January 29, 2020. Therefore, we decided that the Plan does not have to pay for the gingival irrigation and oral surgery procedure.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam
radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton
beam radiation therapy is not medically 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 proton beam radiation therapy. Our
reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician
reviewer found this enrollee is being offered 45 Gy in 3 Gy fractions, which is an equivalent dose of ~48-55 Gy
in 2 Gy fractions. While this might be a consideration for patients with a solitary plasmacytoma, this enrollee is
diagnosed with multiple myeloma. No plausible rationale is provided for offering such a high dose to this
enrollee, which goes against expert guidelines.
For this enrollee being offered palliative radiation therapy, the proposed treatment is not furnished in
accordance with accepted standards of care based upon 1) the use of proton therapy for palliation and 2) dose
escalation for multiple myeloma. The request is 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 proton beam radiation therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on February 18, 2020 from an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that you were told by an insurance agent that if you went to an optical provider that was not a network supplemental vision provider that you could fill out a reimbursement form and you would be reimbursed $250. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. Review of the file show that you purchased the eyewear on February 18, 2020 from an out-of-network provider. Your EOC states, you must use an in-network supplemental vision provider for routine coverage including; routine exam, retinal imaging and eyewear allowance. 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 eyewear purchased on February 18, 2020 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral -periapical each additional radiographic image (D0230) provided on February 17, 2020.You asked the Plan to pay forthe dental services. You say that you were unaware that there were visit limits.The Plan denied your request. ThePlan says you exhausted your benefit frequency limit.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.Your request is not a covered benefit because your records show that you had two sets of intraoral x-rays and one set has already been approved for payment by the Plan. We are unable to approve your request for payment for the additional intraoral x-rays (D0230).Therefore, we decided that the Plan does not have to pay forintraoral -periapical each additional radiographic image (D0230) provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99305) provided on December 23, 2019by an out of network (OON) provider.You asked the Plan to pay forOON nursing facility care. You say that this service was not pre-scheduled.The Plan denied your request. The Plan says this service was not authorized.Medicare rules say thatplans 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 wouldrequire the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe nursing facility care (99305) provided on December 23, 2019 by an out of network (OON) provider.