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

We decided that the Plan does not have to pay an additional amount for the palliative (emergency) treatment of dental pain - minor procedure (D9110), the intraoral - periapical first radiographic image (D0220) the prefabricated post and core in addition to crown (D2954), the crown - porcelain fused to high noble metal (D2750), and the endodontic therapy, premolar tooth (excluding final restoration) (D3320) received October 6 and October 13, 2020 from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services (D9110, D0220, D2954, D2750, D3320). You say that you had a broken tooth that needed to be treated so you went to your local dentist. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 does not offer coverage for endodontic therapy (D3320). If you choose to see an Out-of-Network dentist you might be billed for charges above what the Plan pays, even for services listed with a $0 copayment. The Plan provides coverage for dental codes D9110, D2954, and D2750, and requires 50% coinsurance for each procedure. The Plan's allowed amount for D2954 was $188, and the Plan agreed to pay $94 (50% of the allowed amount) for this procedure. The Plan's allowed amount for D2750 was $703, and the Plan agreed to pay $351.50 (50% of the allowed amount). The Plan's allowed amount for D9110 was $53, and the Plan agreed to pay $26.50 (50% of the allowed amount). The Plan requires a $0 copayment for D0220, up to the allowed amount when received out-of-network. You are responsible for the difference between the Plan's allowed amount and any amount billed by the out-of-network provider.

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 pay an additional amount for the palliative (emergency) treatment of dental pain - minor procedure (D9110), the intraoral - periapical first radiographic image (D0220) the prefabricated post and core in addition to crown (D2954), the crown - porcelain fused to high noble metal (D2750), and the endodontic therapy, premolar tooth (excluding final restoration) (D3320) received October 6 and October 13, 2020 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) received January 25, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that the Plan covers other kinds of oral evaluations and this kind should be covered as well. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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. 

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 comprehensive periodontal evaluation (D0180) received January 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport services provided on July 18, 2020.
You asked the Plan to pay for ambulance transport services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance transport services provided on July 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that the enrollee has been approved to see you in the past. The Plan denied your request. The Plan says the provider is out-of-network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extra heavy duty, extra wide, hospital bed, with weight capacity greater than 600 pounds, with any type side rails, with mattress (E0304).
You asked the Plan to pre-approve the hospital bed. You say that due to the enrollee's requirement of using a Hoyer lift for transfers and his wide body build, he is at risk for falling out of bed with transfers and feels unsafe in his current hospital bed. The Plan denied your request. The Plan says the medical necessity criteria for a heavy-duty hospital bed has not been met.
The Plan must follow Medicare rules. An extra heavy-duty hospital bed is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds. In this case, the records show that the enrollee weighs 290 pounds. Therefore, the enrollee does not meet the
criteria for an extra heavy-duty hospital bed as the enrollee's weight does not exceed 600 pounds. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve extra heavy duty, extra wide, hospital bed, with weight capacity greater than 600 pounds, with any type side rails, with mattress (E0304).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Retacrit (Q5106).
You asked the Plan to pre-approve Retacrit. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been met because the use of the requested drug is an off-label use.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Retacrit. Our reviewer says that the requested treatment is medically necessary. Our physician reviewer found that the requested use of Retacrit is FDA-approved for the enrollee's diagnosis as the enrollee has anemia of chronic kidney disease contributing to the anemia. The documentation supports that the requested drug is safe and effective and otherwise reasonable and necessary 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 Retacrit have been met. Therefore, we decided that the Plan has to pre-approve treatment with Retacrit (Q5106).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgical services rendered on
September 29, 2020.

You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the deductible was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $500 yearly deductible for your covered medical services.

The item or service you asked the Plan to waive the deductible for falls within the out-of-network surgery
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there
is a $500 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that
had not been met at the time these services were received on September 29, 2020. Therefore, we decided that
the Plan does not have to waive the deductible for the outpatient surgical services rendered on September 29,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 13, provisional crowns (D2799) for teeth # 3, 5, 13, and 29, core build up (D2950) for teeth # 3, 5, 13, and 29, a prefabricated post and core in addition to crown (D2954), a gingivectomy or gingivioplasty (D4211) for tooth # 3, and gingival irrigation (D4921) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that you received information from your plan indicating that Medicaid and Medicare will cover all services at 100%. The Plan denied your request. The Plan says 2 crowns are covered per year. The Plan says that the frequency limit has been reached. The Plan says that provisional crowns are not listed as covered service. The Plan says that core build up is not listed as a covered service. The Plan says that prefabricated post and core in addition to a crown is not listed as a covered service. The Plan says that gingivectomy or gingivoplasty is not listed as a covered service. The Plan also says that gingival irrigation is not listed as a covered service either.
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 crowns are listed as covered, the frequency limit has been reached. The record shows that the Plan approved crowns for teeth # 3 and 5. Additionally, provisional crowns, core build up, prefabricated post and core in addition to a crown, gingivectomy or gingivoplasty, and gingival irrigation are not listed as covered services. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 13, provisional crowns (D2799) for teeth # 3, 5, 13, and 29, core build up (D2950) for teeth # 3, 5, 13, and 29, a prefabricated post and core in addition to crown (D2954), a gingivectomy or gingivioplasty (D4211) for tooth # 3, and gingival irrigation (D4921) for all 4 quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like to continue care with this provided. The Plan denied your request. The Plan says there are in-network providers available to provide these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
Please contact that Plan for a list of in-network providers available to provide these services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 67820 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on January 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Estradiol 2 mg tablet.

You asked the Plan to pre-approve Estradiol tablet. You say that the requested drug should be continued as the enrollee has been successful with treatment. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Estradiol 2 mg tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the extraction services (D7140) and core buildup services (D2950) provided February 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay more for the extraction services and core buildup services. You say that you were under the impression the provider was in-network. The Plan denied your request. The Plan says these claims processed correctly, and no additional payment is due.
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 for services received OON. Therefore, we decided that the Plan does not have to pay more for the extraction services (D7140) and core buildup services (D2950) provided February 8, 2021, by an out-of-network (OON) provider.
Your complaint about potentially receiving misinformation regarding the in-network status of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex 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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show the safety and efficacy of the 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 a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a head and neck ultrasound to be provided by an out-ofnetwork
provider.
You asked the Plan to pre-approve ultrasound, soft tissues of head and neck (76536). You say that the enrollee
has a history with the requested provider. The Plan denied your request. The Plan says the service requested
may be provided by participating providers.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a head and
neck ultrasound to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction, erupted tooth or exposed root (D7140) pontic-porcelain fused to high noble metal (D6240) crown-porcelain fused to high noble metal (D6750).

You asked the Plan to pre-approve the dental services. You say that you're appealing the denial because you have a hole in your mouth that should be fixed. The Plan denied your request. The Plan says the requested service is not covered under the plan 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 pre-approve extraction, erupted tooth or exposed root (D7140) pontic-porcelain fused to high noble metal (D6240) crown-porcelain fused to high noble metal (D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve second stage implant surgery (D6011, teeth #3 and #4)
You asked the Plan to pre-approve the dental services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this is not listed as covered under the plan 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 pre-approve second stage implant surgery (D6011, teeth #3 and #4)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6740 x2), and pontic (D6245 x2).
You asked the Plan to pre-approve retainer crowns, and pontic. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 pre-approve retainer crowns (D6740 x2), and pontic (D6245 x2).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the occupational therapy. The Plan denied your request. The Plan says the services are not emergent or urgent and are available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve occupational therapy to be provided by the requested out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 11, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 3, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 11, 2020.