Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency care services provided from
December 30, 2019 to January 21, 2020.
You asked the Plan to waive the copayments for emergency care services. You say that you have visited
multiple times in the past, needed medical attention, and have always been reimbursed in full. You
also say that you are on a fixed income and were expecting to receive a total refund to pay for your other
expenses. The Plan denied your request. The Plan says the copayment amounts you are being charged are
correct.
The Plan must follow Medicare rules. Medicare rules say that items and services obtained outside of the United
States and its territories are not covered by Medicare except in the specific circumstances described in the
previous section. The Plan has a supplemental benefit for worldwide coverage that goes beyond Medicare's
coverage. For that reason, the Plan's rules apply to this case. The Plan covers worldwide emergency care
services. You are responsible for paying for the services up front and requesting reimbursement from the Plan
within 12 months of the date of service with necessary supporting documentation. You must pay $50
copayment for worldwide emergency care coverage.
You requested reimbursement from the Plan in the total amount of $292.31. For date of service December 30,
2019, you have been asked to pay the allowed amount of $8.73 because this is less than the $50 emergency
care copayment. For date of service January 4, 2020, you have been asked to pay $50 copayment for
emergency care. For date of service January 6, 2020, you have been asked to pay the allowed amount of $24.72
because this is less than the $50 emergency care copayment. Therefore, your total copayment responsibility is
$83.45. As a result, the Plan reimbursed you $208.86 out of the $292.31 requested, which is an appropriate
reimbursement amount based on your Plan's benefits.
We looked at the file, Medicare rules, and the Plan rules. Therefore, we decided that the Plan does not have to
waive the copayments for emergency care services provided from December 30,
2019 to January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane inj.
You asked the Plan to pre-approve Durolane (J7318). You say that you want the enrollee treated with
Durolane. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and
had a contraindication or intolerance to Monovisc and Orthovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Durolane (J7318). Our reviewer says
that the drug is not reasonable and medically necessary. Our physician reviewer found criteria for Durolane is
not met. The enrollee has not tried and failed first line therapy for joint pain such as Monovisc or Orthovisc.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane (J7318) have not been met. Therefore, we decided that the Plan does
not have to pre-approve Durolane inj.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second epidural steroid injection.
You asked the Plan to pre-approve the requested injection. You say that caudal injections would be the best
treatment for the enrollee's symptoms. The Plan denied your request. The Plan says there is no documentation
of any significant relief from the last procedure.
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under
certain medical indications.
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 requested injection. Our physician
reviewer found that the enrollee has chronic low back pain. He had a trial of Physical therapy. It is not clear
whether he continued with a home exercise program. He had radiofrequency ablation of his facets and achieved
50% pain relief. He had a caudal epidural steroid injection. The enrollee did not achieve clinically significant
pain relief from the first injection. Therefore, a second injection is not indicated. It is not medically reasonable
or 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 requested injection have not been met. Therefore, we decided that the Plan
does not have to pre-approve a second epidural steroid injection.
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 above.
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 required maximum assistance for transfers. The enrollee required
moderate to maximum assistance for most activities of daily living. The documentation does not support that
the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The documentation does support that the enrollee requires additional physical therapy and occupational
therapy, but does not support that the enrollee requires an intensive inpatient rehabilitation therapy program.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (code D5214).
You asked the Plan to pre-approve the mandibular partial denture. The Plan denied your request. The Plan says
the remaining lower teeth exhibit poor periodontal condition, poor prognosis, and may need to be extracted in
the future. The Plan also says this service is 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
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 pre-approve the mandibular partial denture. Our
reviewer says that the mandibular partial denture is not medically necessary. Our physician reviewer found the
enrollee has two remaining lower teeth, both located in the lower right quadrant. Our reviewer found that the
proposed appliance would require substantial support from these remaining teeth to function properly. Tooth
#26 has approximately 75% bone missing and has been approved for removal, and tooth #27 has approximately
60% bone missing. In general, for proper functioning of a metal based partial denture there must be at least
50% supporting bone remaining on the abutment teeth to support the appliance and limit damage to those teeth
taking the extra forces. Our physician reviewer found that the criteria for partial dentures specifically
states that at least 50% remaining bone must be present on the abutment teeth to allow for coverage. Our
reviewer also found that given the bone levels seen on the supplied radiographs of tooth #27, which would be
the only abutment for the appliance, being significantly less than 50%, there can be no finding of medical
necessity for the requested procedure of a tooth supported partial denture under code D5214.
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 mandibular partial denture have not been met. Therefore, we decided that
the Plan does not have to pre-approve a mandibular partial denture (code D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953), the surgical extractions (D7210) for teeth # 30 and 32, and the unspecified oral surgery (D7999) provided on October 2, 2019 by the out of network provider.
You asked the Plan to pay for the dental services. You say that the services were previously authorized by the Plan. The Plan denied your request. The Plan says services received out of network are not covered. The Plan also says that the dentist in this case is not a network 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, dental services received out of network are not covered. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953), the surgical extractions (D7210) for teeth # 30 and 32, and the unspecified oral surgery (D7999) provided on October 2, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) and core buildup, including any pins when required (D2950) provided on October 2, 2019.
You asked the Plan to pay for the crown and core buildup. You say that you should have only paid $350 for the crown but really paid $600. You also say that you did not receive an upgraded crown or crown lengthening that you were billed for. The Plan denied your request. The Plan says you were charged appropriately based on your benefits.
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, contract says that you must pay a $0 to $425 copay for Comprehensive dental services. The record shows that the Plan confirmed with the provider's office that you were informed of the additional fees of $250 for the elective procedures and you also signed indicating acknowledgement. Therefore, we decided that the Plan does not have to pay for the crown (D2750) and core buildup, including any pins when required (D2950) provided on October 2, 2019.
Your complaint about being dissatisfied with the 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 12, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan denied this incorrectly. The Plan
denied your request. The Plan says without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 12, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (code D2393) provided on August 7, 2019.
You asked the Plan to pay for the resin-based composite. You say that this service was deemed necessary and appropriate by the enrollee's dentist. You also say the Plan provides a $2,000 annual benefit but denied the dental work on a single tooth. The Plan denied your request. The Plan says this service is not covered by the enrollee's 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. Therefore, we decided that the Plan does not have to pay for the resin-based composite (code D2393) provided on August 7, 2019.
Your complaint about the Plan not being sincere about their maximum annual benefit 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 pre-approve a porcelain fused to high noble metal crown (D2750), 2
pontics (D6240), and 2 retainer crowns (D6750).
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says that
porcelain fused to high noble metal crowns, pontics, and retainer crowns are not specifically 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 dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
porcelain fused to high noble metal crown (D2750), 2 pontics (D6240), and 2 retainer crowns (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342) for all
4 quadrants.
You asked the Plan to pre-approve the dental services. You say that you are not getting the correct teeth
cleaning from your dentist. You say that the dentist is still getting paid for the services. You also say that you
had to wait a long time for only a 5 minute cleaning. The Plan denied your request. The Plan says periodontal
scaling and root planing is covered once per quadrant every 2 years. The Plan says that the frequency limit for
this service has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and periodontal scaling and root
planing is listed as a covered service, the frequency limit of once every 2 years has been reached. The record
shows that you last received periodontal scaling and root planing for all 4 quadrants on July 11, 2019.
Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing
(D4342) for all 4 quadrants.
Your complaint about a long wait prior to receiving the services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on February 18, 2020.
You asked the Plan to pay for eye refraction. You say that this was a follow-up appointment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is not a Vision 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 obtained through a Vision provider. We looked at the file and the Plan's rules. This service is not covered by the Plan's routine vision benefits because the provider is not a Vision network provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) and ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (CPT Code 92014) provided on October 10, 2019 by a non-participating provider.
You asked the Plan to pay for the services. You say that you disagree with the responsibility. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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.
Review of the file show that you received determination of refractive state (CPT Code 92015) and ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (CPT Code 92014) provided on October 10, 2019 by a non-participating provider. You are asked to pay a $25 copayment for the ophthalmological services and you are responsible for the eye refraction. This provider is not a provider and your supplemental benefits do not apply to the eye refraction. Therefore, we decided that the Plan does not have to pay for determination of refractive state (CPT Code 92015) and ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits (CPT Code 92014) provided on October 10, 2019 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased from, an out-of-network provider, on August 1, 2019.
You asked the Plan to pay for the eyewear. You say that you disagree with the processing of the claim. The Plan denied your request. The Plan says you received an explanation of benefits (EOB) and believed it to be a bill. The Plan states it was only a breakdown of how the claim paid.
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. We looked at the file and the Plan's rules. The EOC is only a breakdown of how the claim paid. Your EOC clearly states, your frames and lens package is $200 (combined in and out-of-network) benefit toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider (1 per
calendar year). You pay any amount over $200 retail price. Therefore, we decided that the Plan does not have to pay for the eyewear purchased from, an out-of-network provider, on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and the prophylaxis (D1110) provided on August 22, 2019.
You asked the Plan to pay for the dental services. You say that when you called to change your dental plan, you were advised that the provider was in network. You also say that the provider was on the list of in network providers supplied by the Plan. The Plan denied your request. The Plan says the provider is not in network with the Plan. The Plan also says there is no record that you called to confirm that this provider was in network prior to receiving the services on August 22, 2019.
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 a periodic oral evaluation, and prophylaxis are listed as covered services, they are not covered when you receive these services out of network. The record shows that the provider's contract with the Plan ended on January 1, 2019. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), and the prophylaxis (D1110) provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-ray (D0220) and the consultation with an oral evaluation (D9310) provided on November 5, 2019.
You asked the Plan to reimburse you for the dental services. You say that you should be reimbursed. You say that the wrong copayment amounts were used. The Plan denied your request. The Plan says the claim was processed correctly. The Plan says that the Schedule of Benefits states "Members pay 80% of Specialist's Usual & Customary Fee per procedure when receiving specialty services approved by the plan." The Plan also says that the copayment amounts in the chart are for services performed by a general dentist.
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 claim was processed with the correct copayment amount. The copayment amounts in the chart are for services that you receive from a general dentist. The provider in this case is a dental specialist thus the 80% copayment applies. Therefore, we decided that the Plan does not have to reimburse you for the periapical x-ray (D0220) and the consultation with an oral evaluation (D9310) provided on November 5, 2019.