Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a privacy flap for the approved power wheelchair.
You asked the Plan to pre-approve a privacy flap. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a privacy flap does not serve a medical purpose and is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a privacy flap for the approved power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you disagree with the plan's denial. The Plan denied
your request. The Plan says the enrollee does not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network outpatient mental health care provided to the enrollee from July 1, 2020, to January 18, 2021.
You asked the Plan to pay for out of network care. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 Plan contract also states outpatient mental health care requires prior authorization both in and out of network. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for out of network outpatient mental health care provided to the enrollee from July 1, 2020, to January 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on April 7, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you were under the impression that this was your annual check-up and should not be responsible for a copayment. The Plan denied your request. The Plan says you have been asked to pay 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 a $5 copayment for medical care or surgery services in a primary care physician's office.
You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows this visit was less than 12 months of your last annual wellness visit was on October 21, 2020. 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 provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the four crowns provided on February 1, 2021, and February 17, 2021.
You asked the Plan to waive the coinsurance for the crowns. You say that you were told the price for your crowns would be around $600 to $700. You also say that you would like the coinsurance for the crowns to be lowered. The Plan denied your request. The Plan says both claims have been processed correctly, and the coinsurance cannot be waived.
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, you are responsible for a 50% coinsurance for covered Major Services including crowns. Therefore, we decided that the Plan does not have to waive the coinsurance for the four crowns provided on February 1, 2021, and February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy provided on February 17, 2021.
You asked the Plan to waive the copayment for the cystoscopy. You say that this was not a surgery procedure and you do not agree with the charge. The Plan denied your request. The Plan says the copayment 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 $350 copayment for each Medicare-covered visit to an in-network outpatient hospital facility.
You have been asked to pay a $350 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The cystoscopy is considered a surgical service. 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 cystoscopy provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator.
You asked the Plan to pre-approve the requested item. You say that you need a portable oxygen tank to have your therapy done. The Plan denied your request. The Plan says the requested portable oxygen concentrator is not a brand covered by the Plan.
The Plan follows Medicare rules. The rules say that plans may specify brands and manufacturers as preferred.
The requested provider in this case is not a preferred brand with the Plan. The Plan has preferred brands available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve a non-preferred brand. Therefore, we decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 13, 2021.
You asked the Plan to waive the copayment the laboratory work. You say that you have had blood tests done many times and have never had two copayments. The Plan denied your request. The Plan says you have been asked to pay 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 a $5 copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services.
You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory work provided on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 10, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the hospital is an authorized provider, and the service rendered by the house provider should also be included in that authorization. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided on February 10, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided on September 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided February
3, 2021.
You asked the Plan to pay for the re-cement or re-bond crown. You say that you were told the provider was innetwork.
The Plan denied your request. The Plan says a one-time exception has been granted to allow the
claims to process at an in-network level of coverage however the re-cement or re-bond crown is not a covered
service under your dental 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, 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 recement
or re-bond crown (D2920) provided February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a full mouth debridement (D4355) provided on December
23, 2020.
You asked the Plan to pay for a full mouth debridement. You say that you are on a limited income and want the
Plan to pay for the service. The Plan denied your request. The Plan says a full mouth debridement is only
allowed once every 3 years and will not be covered if performed less than 1 calendar year after an evaluation.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a full mouth debridement have not been met. Specifically, the record shows you received services
for a comprehensive oral evaluation (D0150) performed on December 01, 2020 and as per the EOC, you cannot
receive services under D4355 less than 1 calendar year after receiving D0150. Therefore, we decided that the
Plan does not have to pay for a full mouth debridement (D4355) provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on March 1, 2021 by an OON provider.
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that the in-network and OON dental coverage is the same, with a $1,000 limit. You also say that this bill should have been paid in full. The Plan denied your request. The Plan says this claim processed correctly and paid according to the Plan benefits for services obtained OON.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on March 1, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on May 8, 2020.

You asked the Plan to waive the copayment for the upper GI endoscopy. You say that this procedure was pre-approved. The Plan denied your request. The Plan says you have been asked to pay 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 a $335 copayment for surgery services at an in-network outpatient hospital. 

You have been asked to pay a $335 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 upper GI endoscopy provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve injection(s), of diagnostic or therapeutic substance, without imaging
guidance (62322). You say that the enrollee needs the injection for low back pain relief. The Plan denied your
request. The Plan says the clinical information provided does not include a treatment plan with spinal levels
and does not describe a plan to use imaging guidance.
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 injection(s), of diagnostic or therapeutic
substance, without imaging guidance (62322). Our reviewer says that the requested service is not considered
medically reasonable and necessary in this case. Our physician reviewer found there is inadequate
documentation of the patient's history and physical exam by the physician. There are no imaging reports
submitted. The standard of care is either computed tomography guidance or fluoroscopic guidance. Therefore,
the request is deemed 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 injection(s), of diagnostic or therapeutic substance, without imaging guidance
(62322) have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural
steroid injection.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided
on March 10, 2021.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you got an
approval letter and was unaware of any copayment. The Plan denied your request. The Plan says the copayment
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 $200
copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine, and stress
tests).
You have been asked to pay a $200 copayment for the myocardial perfusion imaging. The myocardial
perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 myocardial perfusion imaging provided on
March 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient procedure, to remove a
tunneled catheter (36590) provided on January 5, 2021.
You asked the Plan to waive the copayment for an outpatient procedure. You say that you do not understand
why you have to pay more than the Plan paid. The Plan denied your request. The Plan says the copayment you
are being charged is correct.
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 $325
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $325 copayment for an outpatient procedure. The EOC confirms $325 is the required copayment for this service. 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 outpatient procedure, to remove a tunneled catheter (36590) provided on January 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport provided on February 22, 2021.
You asked the Plan to waive this copayment. You say that you were ultimately diagnosed with Covid-19 and should have no copayment. The Plan denied your request. The Plan says ambulance transport copayments were not in the category of services that Medicare provided at no charge. This copayment was based on the service provided and the Plan contract agreement.
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 $225 copayment for ambulance transport. The Plan is correct in that ambulance transport is not among those services Medicare indicated would be free of charge if provided by a facility or physician for treatment of Covid-19.
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 $225 copayment charged for ambulance transport provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), a core buildup (D2950), and sales tax
(D9985) provided on February 10, 2021.
You asked the Plan to pay for a crown, a core buildup, and sales tax. You say that you did not use your dental
benefits in 2019 or 2020 and would like these services to be covered. The Plan denied your request. The Plan
says the crown is a covered benefit, but you have exceeded the frequency limit of one every year. A core
buildup is not a covered benefit. Sales tax is not paid when the rendering services are not paid. Dental benefits
cannot be carried over from one calendar to the next if they are not used.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a crown, a core buildup, and sales tax have not been met. Specifically, the record shows that you
had exceeded the frequency limit for crowns prior to this service on February 3, 2021. Additionally, a core
build up is not a covered service and sales tax is not paid when the rendering services are not paid. Therefore,
we decided that the Plan does not have to pay for a crown (D2740), a core buildup (D2950), and sales tax
(D9985) provided on February 10, 2021.