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

We decided that the Plan does not have to pay for 9 extractions (D7210), a frenulectomy (D7960), general anesthesia (D9222, D9223) and the alveoloplasties (D7310) provided on December 7, 2020.
You asked the Plan to pay for the dental services. You say that you do not understand why these services are not covered or why it is so hard to find a Plan to cover services for dentures. The Plan denied your request. The Plan says these services are not covered by your dental benefit or were provided in a quantity that exceeds what is allowed by the 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 can cover certain preventative and comprehensive services. This includes one simple extraction per lifetime.
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 or were provided in excess of what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for 9 extractions (D7210), a frenulectomy (D7960), general anesthesia (D9222, D9223) and the alveoloplasties (D7310) provided on December 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on February 5, 2021.
You asked the Plan to waive the copayment for lab work. You say that you think this is being billed incorrectly. 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 $45 copayment for outpatient diagnostic tests/in-network/lab/outpatient hospital. You have been asked to pay a $45 copayment for lab work. The lab was provided by an outpatient hospital; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/in-network/lab/outpatient hospital 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 lab work provided by a participating provider on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a participating provider on February 11, 2021.
You asked the Plan to waive the copayment for specialist telehealth services. You say that you do not agree with this copayment. 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 $45 copayment for physician/practitioner services/specialist. You have been asked to pay a $45 copayment for specialist telehealth services. The correct copayment has been applied to the services that were provided. Specialist telehealth services fall within the physician/practitioner services/specialist 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 specialist telehealth services provided by a participating provider on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be performed by an oral surgeon.
You asked the Plan to pre-approve dental services. You say that if you do not get this taken care of it may cause gum disease. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because dental services performed by an oral surgeon 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 pre-approve dental services to be performed by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you disagree with this denial based on the enrollee's
physical and medical needs. The Plan denied your request. The Plan says the denial of authorization for IRF
service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
While the enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391), four resin-based composites - one surface, anterior (D2330) and two intraoral - periapical additional radiographic images (D0230) provided January 5, 2021
You asked the Plan to pay for the additional resin-based composites and intraoral x-rays. You say that you were unhappy with previous treatment and requested additional services. The Plan denied your request. The Plan says these services have been covered up to the Plan's limit and additional 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. The Plan covers resin-based composites twice a year and intraoral x-rays once a year. We looked at the file and Medicare rules. The Plan provided documentation showing that one intraoral x-ray
and two resin-based composites were covered according to the Plan contract on the same date of service. Therefore, we decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391), four resin-based composites - one surface, anterior (D2330) and two intraoral - periapical additional radiographic images (D0230) provided January 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 13, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on January 13, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 22,
2020.
You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received an office visit on the date of service at issue in this appeal. The Plan
says that the correct copayment has applied per your contract with the Plan.
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 specialist services.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an office visit
provided by a specialist on December 22, 2020. You have been asked to pay a $30 copayment for the office
visit. The office visit falls within the Physician/Practitioners 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 the office visit provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection provided on November 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an injection. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained 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 an injection provided on November 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hepatitis B vaccine (90746).
You asked the Plan to pre-approve the hepatitis B vaccine. You say that the enrollee is requesting this vaccine because he is going on a mission trip to Africa, and does not want to acquire any possible Hepatitis B. The Plan denied your request. The Plan says the enrollee is not in an intermediate or high risk group for contracting Hepatitis B.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for hepatitis B vaccine if you are at an intermediate or high risk for contracting hepatitis B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hepatitis B vaccine have not been met. Therefore, we decided that the Plan does not have to pre-approve a hepatitis B vaccine (90746).
Benefits for the hepatitis B vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on November 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you request prior authorization but a written authorization was never received from the Plan. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for 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 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 an x-ray provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you were admitted for an exacerbation of multiple sclerosis. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional visits. You say that the enrollee will benefit from continued physical therapy. The Plan denied your request. The Plan says the enrollee does not require treatment by a physical therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional visits. Our physician reviewer found that the enrollee has had prior therapy. The records do not demonstrate specific deficits that require formal physical therapy or that the unique skills of a professional therapist are required to safely and effectively provide treatment.
The enrollee has been instructed in home exercises. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain her current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services.
You asked the Plan to pay for inpatient services. The Plan denied your request. The Plan says the enrollee will not require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. The file shows that inpatient hospital care for the enrollee's surgery was requested. 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 pay for inpatient services. Our physician reviewer found that the enrollee is medically stable. The review indicates that the records do not show the enrollee's necessary hospital care will span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 180 additional routine transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that you need additional trips to get to and from the gym as instructed by your nutritionist to lose weight. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation up to 48 one-way trips per calendar year to plan approved locations.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide 180 additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on January 20, 2021.
You asked the Plan to waive the copayment for lab work. You say that you do not agree with this copayment. 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 $0-$15 copayment for outpatient diagnostic tests/lab work/outpatient hospital. You have been asked to pay a $15 copayment for lab work. The correct copayment has been applied to the lab work that was provided. Lab work falls within the outpatient diagnostic tests/lab work/outpatient hospital 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 lab work provided by a participating provider on January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism correcting intraocular lens (V2787) received February 4, 2020.
You asked the Plan to pay for the astigmatism correcting lens. You say that you were told this would be paid for by the Plan. The Plan denied your request. The Plan says Medicare does not cover astigmatism correcting lenses.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for the astigmatism correcting intraocular lens (V2787) received February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are at high risk for a blood clot and need rehabilitation to stabilize your limbs. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.