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

We decided that the Plan does not have to waive the out of network cost share forthe periodic oral evaluation (D0120), the cleaning (D1110), and the full series x-rays (D0210) provided on September 23, 2020.You asked the Plan to waive the out of network cost share forthe dental services. You say that you were not aware that the dentist was not a part of your program. You say that had you known this, you would have gone to another dentist. You say that you do not have money to pay for these extra charges. You also say that if the charges are not paid, you will have to find a new dental plan.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that while services out of network are still covered, you will pay more out of pocket.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 waive the out of network cost share forthe periodic oral evaluation (D0120), the cleaning (D1110), and the full series x-rays (D0210) provided on September 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to an out-of-network LTACH.
You asked the Plan to pre-approve the LTACH services. You say that the transfer is medically necessary. The
Plan denied your request. The Plan says this is not a denial of acute level of care. The Plan states they will
continue to cover acute level care at the current hospital. The Plan states this will continue as long as it is
medically necessary and the current acute care hospital can provide acute care services until the member's
condition allows transfer to a lower level of care, such as skilled nursing facility, acute inpatient rehabilitation,
home health care, nursing home, or home.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve transfer to an out-of-network LTACH.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B injection provided on May 14, 2020.You asked the Plan to waive the coinsurance forthe Part B injection. You say that thismedication has been 100% covered in the past. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the plan-allowed amount for in-network Medicare Part B-covered drugs. You have been asked to pay $169.67 which is 20% of the allowed amount for the Part B injection. The allowed amount is $848.34. ($848.34 x 20% = $169.67). The Part B injection falls within the "Medicare Part B prescription 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 forthe Part B injection provided on May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft at time of implant placement (D6104) and
problem focused limited oral evaluation (D0140), or pay more for the surgical extraction (D7210) and
endosteal implant (D6010) provided on July 2, 2020.
You asked the Plan to pay for the bone graft and problem focused limited oral evaluation, extraction and
endosteal implant. You say that you decided to do an extraction and implant to assure a long-term successful
restoration. The Plan denied your request. The Plan says the bone graft at time of implant placement is not a
covered benefit. The Plan also says that your $1,000 benefit for non-Medicare covered services had 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 bone graft at time of implant
placement (D6104) is not among those covered under this benefit. The contract also says that the Plan offers up
to $1,000 every year for combined in and out-of-network non-Medicare covered comprehensive dental
services. The record shows that you met the annual maximum benefit on [September 6, 2019] and your annual
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the bone
graft at time of implant placement (D6104) and problem focused limited oral evaluation (D0140), or pay more
for the surgical extraction (D7210) and endosteal implant (D6010) provided on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe injection, pegfilgrastim-bmez, biosimilar, (ziextenzo) (Q5120) provided August 3, 2020 to August 24, 2020.You asked the Plan to waive the copayment forthe injection services. You say that you have a couple hundred left over each month to pay $40 to specialists but these charges is far beyond your checkbook.The Plan denied your request. The Plan says the claim was processed and the correct coinsurance was applied per the Evidence of Coverage.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 injection supplied by the physician, in addition to office copayment. You have been asked to pay $1,522.94 ($761.47 x2) for the injection services. The injection services fall within the Physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based onyour 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 injection, pegfilgrastim-bmez, biosimilar, (ziextenzo) (Q5120) provided August 3, 2020 to August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite services received on December 17, 2019.You asked the Plan to pay forthe resin-based composite services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.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 resin-based composite services once percalendar year. We looked at this physician's review, the file, and Medicare rules. The plan covers one amalgam (silver) or resin-based composite (white) fillingper calendar year. Review of the file shows that you previously received this service on September 21, 2019. Based on this information, we decided that the Plan's rules for coverage of the resin-based composite services have not been met.Therefore, we decided that the Plan does not have to pay forthe resin-based composite services received on December 17, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on October 19, 2020.You asked the Plan to pay forthe dental services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the dental provider has opted out of participating with Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue inthis appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe dental services provided on October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye exam (92014), deluxe eyeglass frames (V2025) and single vision, bifocal, trifocal, glass or plastic lens; per lens (V2100) provided on September 17, 2020.

You asked the Plan to pay for eye exam, eyeglasses frames and lens. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered under your benefit plan.

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 more vision care than what Medicare covers, but you must use a doctor in our vision network.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of eye exam, eyeglasses frames and lens have not been met. Specifically, you received the services from a provider outside the Plan's vision network. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for eye exam (92014), deluxe eyeglass frames (V2025) and single vision, bifocal, trifocal, glass or plastic lens; per lens (V2100) provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an oncology visit (99214) provided January 21, 2020.
You asked the Plan to waive the copayment for the oncology visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $45 copayment for specialist visits. You have been asked to pay a $45 copayment for the oncology visit. The oncology visit falls within the specialist visits 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 oncology visit (99214) provided January 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted procedure, femur or knee services coded 27599
provided on October 3, 2019.
You asked the Plan to pay for the unlisted procedure, femur or knee 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
supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 27599 is unlisted procedure, femur or knee.
We find that CPT code 27599 is not supported in the medical record. Specifically, the operative report did not
include documentation to meet the guidelines of an unlisted femur or knee procedure; therefore, this code
cannot be verified. Based on this information, we decided that Medicare rules for coverage of the unlisted
procedure, femur or knee services have not been met. Therefore, we decided that the Plan does not have to pay
for the unlisted procedure, femur or knee services coded 27599 provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran annual wellness visit (G0439) on August 19, 2020.You asked the Plan to pay foran annual wellness visit. You say that you believed this appointment was a follow-up from your last appointment with your prior physician and understood that this appointment was medically necessary for continuing your course of care.The Plan denied your request. The Plan says rules for payment have not been met.The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.Therefore, we decided that the Plan does not have to pay foran annual wellness visit (G0439) on August 19, 2020.Your complaint about receiving erroneous or ambiguous information from your provider about the nature of your office visitis 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug testing services (80307 and G0480). You say that you would like reconsideration because these services should be covered. The Plan denied your request. The Plan says these services were provided by an out-of-network provider and were not authorized by 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 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 the medical services provided on September 28, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve ranibizumab.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has macular edema secondary
to neovascular age-related macular degeneration. There is evidence in the medical literature that ranibizumab is
equivalent to Avastin (bevacizumab) for the treatment of this condition. The health plan's argument that the
patient must have already tried and failed treatment with bevacizumab is unrelated to a drug formulary step
plan and has no clinical basis. There is no evidence that the enrollee had failed treatment with bevacizumab in
the past, however, there is medically no indication to begin treatment with bevacizumab, since the clinical
effect of the two drugs is equal for this disease.
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 been met. Therefore, we decided that the Plan has to preapprove
ranibizumab.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forcataract surgery (66984) and Phenylephrine-Ketorolac ophthalmic irrigation solution (J1097) received on May 28, 2020.You asked the Plan to waive the copayments forcataract surgery and Phenylephrine-Ketorolac ophthalmic irrigation solution. You say that you were quoted a different copayment prior to the surgery.The Plan denied your request. The Plan says the correct copayments were 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 $250 copayment for Medicare-covered surgery and a $50 copayment foreach Medicare-covered Part B drug. You have been asked to pay a $250 copayment for cataract surgery and a $50 copayment for Phenylephrine-Ketorolac ophthalmic irrigation solution. Cataract surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Phenylephrine-Ketorolac ophthalmic irrigation solution falls within the "Medicare Part B Prescription 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 copayments forcataract surgery (66984) and Phenylephrine-Ketorolac ophthalmic irrigation solution (J1097) received on May 28, 2020.Your complaint about receiving erroneous or ambiguous information about your cost-sharing responsibilityis 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (G0157, G0299) provided January 14,
2020 to February 12, 2020.
You asked the Plan to pay for the home health services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the claim did not include required elements.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code G0157 & G0299 is not supported in the medical record. Specifically, the claim did not
include the appropriate "Q" code to denote where the home health services were provided. Based on this
information, we decided that Medicare rules for coverage of the home health services have not been met.
Therefore, we decided that the Plan does not have to pay for home health services (G0157, G0299) provided
January 14, 2020 to February 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have pay more toward the cost of eyewear provided on September 22, 2020.
You asked the Plan pay more toward the cost of the eyewear. You say that it is unfair that the discounted rate is
not extended to the subscriber. The Plan denied your request. The Plan says the appropriate benefit allowance
was applied to the claim in dispute.
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 any
amount over a $300 retail price for eyeglasses and a pair of lenses or contact lenses at a network optical
provider, per calendar year.
You have been asked to pay $364 for the eyewear. The total retail price of the eyewear in dispute was $755.
Your $300 benefit allowance was subtracted from that retail price, leaving $455 owed. As a network provider,
an additional 20% (equaling $91) was discounted from that remaining balance. The eyewear falls within the
frames and lens package 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 pay more toward the cost of eyewear
provided on September 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram, routine ECG with at least 12 lead (93000) provided on September 23, 2020.You asked the Plan to waive the copayment foran ECG. You say that the service should be covered.The Plan denied your request. The Plan says the cost share was applied 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 $30 copayment for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $30 copayment for an ECG. This service falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You were asked to pay $18.75 out of the $30 copayment. 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 foran electrocardiogram, routine ECG with at least 12 lead (93000) provided on September 23, 2020