Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion drugs you received on November 24, 2020.
You asked the Plan to waive the coinsurance for the infusion drugs. You say that you have never been charged for these drugs in the past. 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 Medicare Part B drugs. You have been asked to pay 20% coinsurance for the infusion drugs. The infusion drugs fall within the Medicare Part B drugs 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 for the infusion drugs you received on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit you had with a
pulmonologist and the respiratory flow volume loop test you had on October 23, 2020.
You asked the Plan to waive the cost sharing for the office visit and the diagnostic test. You say that you do not
agree with the amount being charged. The Plan denied your request. The Plan says you were charged this cost
sharing correctly. The Plan says that for the diagnostic test, the allowed amount ($41.51) is less than your
copayment responsibility, so you are responsible for the full allowed amount for the test.
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 $40
copayment for specialist visits and a $50 copayment for diagnostic tests.
You have been asked to pay a $40 copayment for the office visit and a $50 copayment for the diagnostic test.
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 cost sharing for the office visit you had with a pulmonologist and the
respiratory flow volume loop test you had on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 17, 2021 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services by the member's primary care physician.
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 had network providers available who could have provided 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 lab work provided on January 17, 2021 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 27,
2020.
You asked the Plan to waive the copayment for ambulance services. You say that you have insurance for the
purpose of paying for services. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for ambulance services.
You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the
ambulance 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 for ambulance services
provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), the complete series x-ray (D0210), and the application of fluoride varnish (D1206) provided on January 14, 2021.
You asked the Plan to pay for the dental services. You say that your dentist retired. You say that you were not advised that the new dentist would be out of network. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that care rendered by a provider that is not part of the supplemental dental network is 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, dental services performed outside of the supplemental dental network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), prophylaxis (D1110), the complete series x-ray (D0210), and the application of fluoride varnish (D1206) provided on January 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan provided on March 16, 2021.
You asked the Plan to pay for the CT scan. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for the CT scan provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2-surface fillings (D2392 x 4), the 3-surface fillings
(D2393 x 2), the crown (D2740), and the core build up (D2950) provided on March 22, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied
your request. The Plan says there is a maximum allowance of $1,000 for preventive and comprehensive dental
services every year. The Plan also says that the allowance has been exhausted.
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 maximum allowance has been
exhausted. The record shows that the Plan paid $350 for dental services performed on March 9, 2021, and $650
for dental services performed on March 22, 2021. $350 + $650 = $1,000. Therefore, we decided that the Plan
does not have to pay for the 2-surface fillings (D2392 x 4), the 3-surface fillings (D2393 x 2), the crown
(D2740), and the core build up (D2950) provided on March 22, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Radicava (J13101).
You asked the Plan to pre-approve Radicava. You say that the requested drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage of Radicava have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Radicava. Our reviewer says that the requested drug is medically necessary and reasonable. Our physician reviewer found that the member is said to have a diagnosis of amyotrophic lateral sclerosis (ALS). The records provided would support that Radicava may be effective for the member. The patient has a diagnosis of ALS. The patient's clinical information provided does place her into the populations in which the drug has been shown (by current literature to be of benefit/utility. The member is noted to have a scores on the Amyotrophic Lateral Sclerosis Functional Rating Scale above 2 in all categories. In this setting, the drug could be reasonably expected to be of benefit/utility for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Radicava have been met. Therefore, we decided that the Plan has to pre-approve Radicava (J13101).
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 waive the copayment for the office visit you had at your Primary Care Provider's (PCP) office on November 18, 2020.
You asked the Plan to waive the copayment for the visit to your PCP's office. You say that this copayment should be waived because you saw a nurse practitioner instead of the doctor The Plan denied your request. The Plan says you were charged this copayment 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 a $10 copayment for visits or consultations in locations with your primary care provider. You have been asked to pay a $10 copayment for the visit to your PCP's office. Your Evidence of Coverage
states that this copayment applies to any visit where your PCP is located. This means that the copayment applies when you see a nurse practitioner at this location as well. 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 the office visit you had at your Primary Care Provider's (PCP) office on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a
participating provider on December 16, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with
these copayments. 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 $30
copayment for physician/practitioner services/specialist visit.
You have been asked to pay a $30 copayment for a specialist office visit. A specialist office visit falls within
the physician/practitioner services/specialist visit benefit category. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for a specialist office visit provided by a participating provider on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit you had with a
pulmonologist and the respiratory flow volume loop test you had on December 18, 2020.
You asked the Plan to waive the cost sharing for the office visit and the diagnostic test. You say that you do not
agree with the amount being charged. The Plan denied your request. The Plan says you were charged this cost
sharing correctly. The Plan says that for the diagnostic test, the allowed amount ($41.51) is less than your
copayment responsibility, so you are responsible for the full allowed amount for the test.
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 $40
copayment for specialist visits and a $50 copayment for diagnostic tests.
You have been asked to pay a $40 copayment for the office visit and a $50 copayment for the diagnostic test.
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 cost sharing for the office visit you had with a pulmonologist and the
respiratory flow volume loop test you had on December 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (codes 99285 and 99053) provided on December 19, 2020.
You asked the Plan to pay for codes 99285 and 99053. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not pay for services provided to enrollees in custody under a penal statute unless certain criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee was in custody at the time these services were provided as evidenced by the medical records. Medicare payment may not be made for these services. Therefore, we decided that the Plan does not have to pay for the medical services (codes 99285 and 99053) provided on December 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and
prophylaxis provided on October 6, 2020.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that your
dental program allows two dental cleanings per year. You also say that you had one cleaning on January 7,
2020, and a second cleaning on October 6, 2020. The Plan denied your request. The Plan says you have
reached your annual dental benefit maximum.
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 Plan offers a $2,000 annual dental
benefit maximum. The record shows that you met the annual maximum benefit on July 29, 2020 and your
annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the
periodic oral evaluation, bitewing x-rays, and prophylaxis provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior fusion procedure (22612).
You asked the Plan to pre-approve a posterior fusion procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
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 a posterior fusion procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a posterior fusion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior fusion procedure (22612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 11, 2020.
You asked the Plan to pay for foot orthotics. You say that you have pain in your feet from bone deformities. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that the enrollee has failed conservative measures and would be a good candidate for Vertiflex. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational and the medically concerning finding of instability is a contraindication to this procedure.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show the safety and efficacy of this device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy and biopsy provided on February 12, 2021.
You asked the Plan to waive the copayment for the colonoscopy and biopsy. You say that you had a routine colonoscopy as a preventative measure and are now being penalized for the polyp. The Plan denied your request. The Plan says when a screening colonoscopy becomes a diagnostic procedure then outpatient surgery cost sharing will apply.
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 for Outpatient Surgery.
You have been asked to pay a $225 copayment for the colonoscopy and biopsy. The colonoscopy and biopsy fall within the Outpatient Surgery 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 the colonoscopy and biopsy provided on February 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit you had with a
pulmonologist and the respiratory flow volume loop test you had on November 20, 2020.
You asked the Plan to waive the cost sharing for the office visit and the diagnostic test. You say that you do not
agree with the amount being charged. The Plan denied your request. The Plan says you were charged this cost
sharing correctly. The Plan says that for the diagnostic test, the allowed amount ($41.51) is less than your
copayment responsibility, so you are responsible for the full allowed amount for the test.
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 $40
copayment for specialist visits and a $50 copayment for diagnostic tests.
You have been asked to pay a $40 copayment for the office visit and a $50 copayment for the diagnostic test.
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 cost sharing for the office visit you had with a pulmonologist and the
respiratory flow volume loop test you had on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontics (D6242) and retainer crowns (D6752) provided on January 18, 2021.
You asked the Plan to pay for the pontics and retainer crowns. You say that you contacted the Plan in July 2020 and were advised that you had coverage for up to $500 for two root canals. You also say your dentist advised that the bridge could wait until 2021. 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 pontics (D6242) and retainer crowns (D6752) provided on January 18, 2021.