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

We decided that the Plan does not have to pay for the two amalgams of one surface and two amalgams of two
surfaces provided on August 16, 2019.
You asked the Plan to pay for the four amalgams. You say that you have never been to a doctor or hospital that
did not get pre-authorization for treatments from your insurance company. You also say that the dentist office
provided you with detailed print outs of what you would have to pay at each visit. The Plan denied your
request. The Plan says benefits for these services had been satisfied and the frequency limitation 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, restorations are limited to two
procedures per calendar year. The record shows that you received two resin-based composites on May 24,
2019, both of which the Plan paid for, and your restorations benefit was then exhausted. Therefore, we decided
that the Plan does not have to pay for the two amalgams of one surface and two amalgams of two surfaces
provided on August 16, 2019.
Your complaint about being misled by the Plan and your dental provider is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on December 4, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that you were told that cleanings would be covered when you got this insurance. You also say that you did not know you were getting a different cleaning because it always feels the same. The Plan denied your request. The Plan says this service is not covered by your dental 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. The Plan contract clearly states that periodontal services are not covered. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350 x 4) and
oral hygiene instruction (D1330) provided on January 22, 2020.
You asked the Plan to pay for the dental services. You say that you made the appointment with the
understanding that the provider was in network. You say that there was no mention of an additional x-ray being
needed, nor that it would be an additional cost. You also say that this dental office is fraudulently charging you
and the plan for extra x-rays. The Plan denied your request. The Plan says the dental services you received 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 2D
oral or facial photographic image (D0350 x 4) and oral hygiene instruction (D1330) provided on January 22,
2020.
Your complaint about being charged for x-rays that you feel you did not receive is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the frames and lenses purchased March 5, 2020 from an out-of-
network provider.
You asked the Plan to pay for the vision services. You say that you were told by the insurance agent that you
could purchase glasses at this provider and the insurance would pay $100. The Plan denied your request. The
Plan says enrollee's must receive their vision services from an in-network provider.
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 provided by an in-network provider.
We looked at the file and the Plan's rules. vision services provided by an out-of-network provider is not
covered Based on this information, we decided that the Plan's rules for coverage of the vision services have not
been met. Therefore, we decided that the Plan does not have to pay for the frames and lenses purchased March
5, 2020 from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two osseous surgeries provided on February 11, 2020 by an OON provider.
You asked the Plan to pay for the osseous surgeries. You say that you were told by a Plan representative that surgery would be covered at 50%. You also say that you were not told that it would be 50% of the allowed amount, and the OON provider could bill you for the balance. The Plan denied your request. The Plan says these services were rendered by an OON 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, since the treating provider is OON, they are allowed to bill you the difference between the billed amount and allowed amount. The records show that your call with the Plan informed you that this service was approved. Therefore, we decided that the Plan does not have to pay for the two osseous surgeries provided on February 11, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic and two retainer crowns provided on March 3,
2020.
You asked the Plan to pay for the pontic and retainer crowns. You say that you elected to enroll in the
enhanced dental plan knowing that you had this procedure planned. You also say that you understood crowns
are a benefit with 50% coverage. The Plan denied your request. The Plan says these services are not covered
benefits under the dental 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 because they are considered prosthodontic services. Therefore, we
decided that the Plan does not have to pay for the pontic and two retainer crowns provided on March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on February 20, 2020.
You asked the Plan to pay for the dental service. You say that you were not advised at your appointment that the service would not be covered. The Plan denied your request. The Plan says the topical application of fluoride varnish is 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 topical application of fluoride varnish (D1206) provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 7 and 9, and a pontic (D6245) for tooth # 8.
You asked the Plan to pre-approve the dental services. You say that tooth # 8 is non-restorable. You say that the post, build up and crown came off and the remaining tooth structure is a bone level with recurrent decay. You also say that tooth # 7 needs a crown due to a large existing restoration with leaking margin. The Plan denied your request. The Plan says the requested dental services are not medically necessary.
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 dental services 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 pre-approve the dental services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the Plan limitations only allow fixed bridgework in limited situations. The reviewer found that the criteria for fixed appliances has not been met and therefore are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 7 and 9, and a pontic (D6245) for tooth # 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two retainer crowns and pontic provided on January 8, 2020.
You asked the Plan to pay for the retainer crowns and pontic. You say that the Plan representative did not inform you of the entire process when you were upgrading your coverage. You also say that another Plan representative later corrected you about your Plan coverage. The Plan denied your request. The Plan says these services 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 under this benefit. Therefore, we decided that the Plan does not have to pay for the two retainer crowns and pontic provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397)
provided on January 28, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says the enrollee's orthosis is still under reasonable useful
lifetime.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee had a knee orthosis (L1833), from a different provider, at the time the knee
orthosis and suspension sleeve was received. This knee orthosis (L1833) serves the same purpose as the knee
orthosis and suspension sleeve at issue. Based on the records provided, there is no indication the orthoses
provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the knee
orthosis (L1833) and suspension sleeve (L2397) provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on June 14, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that the service rendered was a dental cleaning, and not a gum and bones treatment which is what the denial letter was for. The Plan denied your request. The Plan says this service is not a covered benefit. The Plan also says that periodontal maintenance is not a preventative cleaning because it is considered a deep cleaning.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig.
You asked the Plan to pre-approve the wig. You say that the enrollee has been getting chemotherapy due to cancer and has lost her hair. You say that the clinical information provided supports the need for a wig. The Plan denied your request. The Plan says this is a non-covered item by Medicare and is not deemed medically necessary.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is non-covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for infectious agent disease testing provided on January 2, 2020.
You asked the Plan to pay for infectious agent disease testing. You say that you are an independent laboratory contracting with the ordering physician, and the services were provided per the referring provider's request. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this test is not a covered benefit for the diagnoses listed and was performed for screening purposes.
The Plan must follow Medicare rules. Medicare rules say that laboratory testing with procedure code 87507 is covered when billed with diagnosis code R19.7. We looked at the file and Medicare rules. This test is covered for the diagnosis code billed on this claim. The documentation submitted shows that this test was ordered for non-screening purposes. Based on this information, we decided that Medicare rules for coverage of infectious agent disease testing have been met. Therefore, we decided that the Plan has to pay for infectious agent disease testing provided on January 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 15,
2019 to November 22, 2019.
You asked the Plan to pay for the 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 the
documentation does not support the medical necessity required to approve the request for inpatient subacute
rehabilitation level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from November 15, 2019 to November 22,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the documentation supports that you
currently have a power wheelchair.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
Review of the file shows that you currently have a power wheelchair that you received in May 2019. You also
received an evaluation of this current power wheelchair in April 2020 that was found to be in perfectly working
condition. In addition, after the evaluation was completed to your current power wheelchair and it was to be
returned to you, you refused it and states that you did not want it and wanted a replacement instead. Since this
power wheelchair is less than five years old, replacement is not covered. Your current power wheelchair serves
the same purpose as a power wheelchair and accessories. Therefore, we decided that the Plan does not have to
pre-approve a power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2392) for tooth # 21 provided on January 29, 2020.
You asked the Plan to pay for the dental service. You say that you had a filling placed by a previous dentist on this tooth. You say that the filling needed to be replaced by your new dentist as there was a gap between the filling and the tooth. You also say that your new dentist advised that it would cause issues if the filling was not replaced. The Plan denied your request. The Plan says fillings are covered for the same tooth once every 2 years. The Plan says the frequency limit 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 and fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for a filling on tooth # 21 that you received on May 10, 2018. Therefore, we decided that the Plan does not have to pay for the filling (D2392) for tooth # 21 provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on July 23, 2019 by an out of
network provider.
You asked the Plan to pay for an office visit. You say that the non-contracted provider's representative is seeking reconsideration based on medical necessity and states that the rendered services
should be covered as it was considered a follow-up post hospitalization visit. The Plan denied your request. The
Plan says the member presented to the Medical Center for emergency services from April 18,
2019 through April 22, 2019. While there, the member was treated by an out-of-network provider. Following this visit, the member had a follow-up visit on May 07, 2019 which was covered by the plan.
Since that time, the member visited with the non-contracted provider on June 04, 2019 and July 23, 2019 both
of which were not covered by the plan. The July 23, 2019 is not covered as it is 92 days after the emergency
room visit, which is outside of the 7-day time-frame for a follow-up visit to be covered under Plan Directed
Care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on July 23, 2019
by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by out of network provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the services that were provided were provided by an out-of-network provider; therefore, the denial of payment is correct. 
 
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 August 6, 2019 by out of network provider.