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

We decided that the Plan does not have to reimburse you for the provisional crowns (D2799 x 2) provided on May 5, 2020.
You asked the Plan to reimburse you for the dental services. You say that you went to the dentist to have a cavity filled and a crown put on. You say that you were charged more than what you were originally quoted for the services. You say that you are now being charged $300. You also say that you should not owe anything due to the outrageous situation. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000. The Plan says that the annual maximum benefit has been reached in the processing of this claim.
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 annual allowance of $1,000 has been exceeded. The record shows that the Plan paid $438 for services that you received on January 9, 2020, and $562 for the services you receive on May 5, 2020, thus exhausting the annual allowance. The Evidence of Coverage clearly states that you are responsible for any amount over the dental coverage limit. Therefore, we decided that the Plan does not have to reimburse you for the provisional crowns (D2799 x 2) provided on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formanual therapy services provided by a chiropractor from April 20, 2020, to May 27, 2020.You asked the Plan to pay forchiropractic services. You say that these services were necessary to correct your subluxation and should be covered.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.The Plan also says that they have approved coverage for the chiropractic manipulative treatments, so this denial is only for the manual therapy services.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay formanual therapy services provided by a chiropractor from April 20, 2020, to May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-ray (D0220), the extraction (D7210), the biologic materials to aid in soft and osseous tissue regeneration (D4265), the filling (D2391), and the root canal (D3320) provided from September 6, 2020, to September 14, 2020.
You asked the Plan to reimburse you for the dental services. You say that you had a dental emergency. You say that you would like the Plan to help you out with the dental work that you had done and will need in the future. You say that dental work is expensive and has put you in a bad financial situation. The Plan denied your request. The Plan says the services in this case are dental in nature. The Plan says that the services you received are not covered. The Plan also says that the maximum reimbursement of $175 has already been reimbursed.
Medicare generally does not cover dental services. The Plan follows the same rule. Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum reimbursement amount of $175 has been exceeded. The record shows that the Plan reimbursed you $175 towards the limited oral evaluation that you received on September 6, 2020, and the panoramic x-ray that you received on September 8, 2020. Additionally, the services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the periapical x-ray (D0220), the extraction (D7210), the biologic materials to aid in soft and osseous tissue regeneration (D4265), the filling (D2391), and the root canal (D3320) provided from September 6, 2020, to September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
You asked the Plan to pre-approve these services. You say that you are in pain. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a lumbar ESI is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have chronic low back pain. You had a transforaminal epidural steroid injection (TFESI) that did not provide significant pain relief. Given that the TFESI did not provide significant relief, the requested lumbar ESI is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not payable.
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 laboratory services provided on July 14, 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 complete lower denture (D5120) provided on July 31,
2020.
You asked the Plan to pay for the dental item. You say that your benefit maximum is $1,000. You say that it
should cover any service rendered. You say that you are on disability and any unexpected bills cause you
stress. The Plan denied your request. The Plan says dentures are not listed as a covered 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
complete lower denture (D5120) provided on July 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pay forneurology services provided to the enrollee on March 12, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until July 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plandoes not haveto pay forneurology services provided to the enrollee on March 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe crutches you received on July 30, 2019.You asked the Plan to waive the coinsurance forthe crutches. You say that the provided waited so long to billyou for this that it is affecting your credit.  You say that you are not comfortable paying this.The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for durable medical equipment. You have been asked to pay 20% coinsurance for the crutches. The crutches fall within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe crutches you received on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood bank physician services coded 86077 provided on
June 22, 2020.
You asked the Plan to pay for the blood bank physician services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 86077 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the blood bank physician services have not
been met. Therefore, we decided that the Plan does not have to pay for the blood bank physician services coded
86077 provided on June 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran x-ray with four views of the hip (73503) provided on January 17, 2020.You asked the Plan to pay foran x-ray with four views of the hip. You say that this is supported in the records.The Plan denied your request. The Plan says the medical records do not document four views.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report serviceswith the appropriate CPT code.In this case, the CPT Code Manual definition of code 73503 is radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views.We find that CPT code 73503 is not supported in the medical record. Specifically, the submitted medical records do not show that four or more views were taken. Based on this information, we decided that Medicare rules for coverage of an x-ray with four views of the hip have not been met.Therefore, we decided that the Plan does not have to pay foran x-ray with four views of the hip (73503) provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tinted eyeglass lenses.
You asked the Plan to pre-approve the tinted eyeglass lenses. You say that you suffer from dry eye syndrome and would benefit from transition tinted lenses. The Plan denied your request. The Plan says the information they have doo not show that the criteria for coverage have been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve tinted eyeglass lenses.
This decision concerns only the Medicare and supplemental benefits provided by your plan. Benefits for eyewear may be available under your Medicaid benefits. You may contact the Plan for additional information about these benefits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe urgent care services received on June 11, 2020.You asked the Plan to waive the copayment forthe urgent care services. You say that you feel you should not be billed this copayment because you were going straight to the emergency room.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 $45 copayment for each urgent care visit.You have been asked to pay a $45 copayment for the urgent care services. The urgent care services fall within the urgently needed services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe urgent care services received on June 11, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional blood glucose reagent strips (A4253) and
lancets (A4259) for the enrollee.
You asked the Plan to pre-approve the additional supplies. You say that this is medically necessary. The Plan
denied your request. The Plan says a review of the clinical evidence does not show that the diabetes is out of
control.
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 additional supplies. Our reviewer
says that the requested additional supplies are not considered medically reasonable and necessary in this case.
Our physician reviewer found a review of the submitted documentation indicates the enrollee has diabetes
mellitus type 2. The documentation indicates the enrollee is not using insulin, there is no record of blood
glucose levels, or need for closer blood sugar monitoring. Without the support of the documentation, medical
necessity cannot be determined.
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 additional supplies have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional blood glucose reagent strips (A4253) and lancets (A4259) for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 8, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 July 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance, ultrasound guidance, and insertion of tunneled centrally inserted central venous access device provided on October 31, 2019.
You asked the Plan to pay for fluoroscopic guidance (77001), ultrasound guidance (76937), and insertion of tunneled centrally inserted central venous access device (36561). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the diagnosis code is an ICD-9-CM code not to be used for services provided after September 30, 2015.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate ICD code. We find that CPT codes 77001, 76937, 36561 are not reported with a correct diagnosis code. Specifically, the provider did not use an ICD-10-CM diagnosis code. Based on this information, we decided that Medicare rules for coverage of fluoroscopic guidance (77001), ultrasound guidance (76937), and insertion of tunneled centrally inserted central venous access device (36561) have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance, ultrasound guidance, and insertion of tunneled centrally inserted central venous access device provided on October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 18, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for portable X-Ray services. You say that your provider is accepted by Medicare for
these services and is payable. The Plan denied your request. The Plan says the denial of payment for this testing
is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-ofnetwork
with 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 the medical services provided on June 18, 2020 by
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient rehabilitation services provided from May 15, 2020, to May 22, 2020.You asked the Plan to waive the copayment forthe inpatient rehabilitation services. You say that you would like this copayment waived and approved for payment.The Plan denied your request. The Plan says the copayment has applied correctly for this case and no reimbursement is due.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 $225 copayment each day for days 1-7 and a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a total cost share of $985 which is less than the required copayment of $1350 (6 days x $225 copayment) because you hit your out of pocket maximum. The services provided fall within the inpatient hospital 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 forthe inpatient rehabilitation services provided from May 15,2020, to May 22, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from June 28, 2020, to July 27, 2020.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to ahospital or to SNF level of care and ends when the enrollee has gone sixtydays in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from February 26, 2020, to June 27, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least sixtydays in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from June 28, 2020, to July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interspinous and/or interlaminar device for the enrollee.You asked the Plan to pre-approvethe device. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies have not proven that this service or procedure is helpful for treatment of the health problem.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 indenying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety andefficacy. There is no spinal instability and hardware is not needed.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvean interspinous and/or interlaminar device for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on August 1, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that you do not agree with these charges. 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 $20 copayment for outpatient diagnostic tests/x-rays. You have been asked to pay a $20 copayment for an x-ray. An x-ray falls within the outpatient diagnostic tests/x-rays 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 an x-ray provided by a participating provider on August 1, 2020.