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

We decided that the Plan does not have to pay for the provisional splinting (D4320) provided on January 21, 2020.You asked the Plan to pay for the dental service. You say that you have 4 loose front teeth. You say that the splint is to stabilize your teeth from falling out. You also say that this is a preventive service.The Plan denied your request. The Plan says the provisional splinting is not listed as a covered service.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 provisional splinting is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the provisional splinting (D4320) provided on January 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 15, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you submitted your bill for review. You say that the ambulance transported her to an out-of-network hospital. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $265 copayment per date of service regardless of the number of ground ambulance trips. The enrollee has been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that the enrollee was transported by ambulance to the hospital. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a water maker.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says very little clinical information was received about the illness, and the requested item does not serve a primarily medical purpose.
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 water maker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on January 31, 2020.
You asked the Plan to pay for the dental service. You say that this was your first visit to this dentist. You say that he did a complete exploration of your mouth. You also say that, per the Evidence of Coverage, some x-rays are covered. The Plan denied your request. The Plan says the complete series of periapical x-rays is not listed as a covered service.
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. The Evidence of Coverage clearly states that bitewing x-rays are the only x-rays that are covered. Therefore, we decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on January 31, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots provided on December 30, 2019.You asked the Plan to pay for the removal of residual tooth roots. You say that you were told that you have extended dental coverage. You also say that you should be repaid 50% for the recent oral surgery.The Plan denied your request. The Plan says this service is not a covered benefit under the dental plan.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. The Plan only covers non-surgical removal of teeth.Therefore, we decided that the Plan does not have to pay forthe removal of residual tooth roots provided on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that a portable oxygen concentrator is necessary for the enrollee to leave the house. The Plan denied your request. The Plan says the enrollee refused portable oxygen tanks to be used in the home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrollee has a stationary oxygen system in the home and was offered portable oxygen tanks. The portable oxygen tanks serve the same purpose as a portable oxygen concentrator. Medicare only covers home oxygen for needs within the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on December 18, 2019 by an out of network provider.You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397),and the lumbar-sacral orthosis (L0648). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says you did not request prior authorization.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 has network providers available who can provide 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 orthoses provided on December 18, 2019 by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for Nursing Facility Care (99309) provided October 22, 2019.You asked the Plan to pay for the Nursing Facility Care. You say that the services were medically necessary.The Plan denied your request. The Plan says Original Medicare is liable for payment.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 Nursing Facility Care (99309) provided October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopath services received on December 18, 2019.
You asked the Plan to pay for the services. You say that traditional doctors have not been able to resolve the
leg/feet cramps that you have. The Plan denied your request. The Plan says the plan won't pay for excluded
medical services.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.
The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have
to pay for naturopath services received on December 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 44120) provided on November 26, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says an operative note was not submitted for the date of service in question.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. The documentationsubmitted by the non-contract provider does not contain records for the date of services in question. Without these records, it cannot be determined that Medicare covered criteria have been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 44120) provided on November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided from October 7, 2019 through November 25, 2019.You asked the Plan to waive the copayment for wound care. You say that nothing was done in the operating room. You say that only wound care in a regular room was performed.The Plan denied your request. The Plan says the copayments 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 $200copayment for each Medicare-covered outpatient hospital facility visit.You have been asked to pay a $200 copayment for each wound care visit. The total amount you owe is $1,600 ($200/visit x 8 visits = $1,600). Wound care falls within the "Outpatient Surgery, including services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. Wound care 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 wound care provided from October 7, 2019 through November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260).You asked the Plan to pre-approve the semi-electric hospital bed. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the records do not support the coverage criteria for a semi-electric hospital bed.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed. Our reviewer says that the semi-electric hospital bed is not medically necessary for this enrollee. Our physician reviewer found the enrollee's condition does not require position of the body in ways not feasible in an ordinary bed. The enrollee does not require frequent changes in body position. The enrollee's condition does not require special attachments that cannot be fixed and used on an ordinary bed.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 semi-electric hospital bed have not been met.Therefore, we decided that the Plan does not have to pre-approve semi-electric hospital bed (E0260).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says placement in a SNF is not appropriate, and could actually be detrimental.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that 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 has network providers available who can provide 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 assisted living services provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for physician services provided on July 15, 2019. You asked the Plan to waive this copayment. You say that no physician services were provided on that day.The Plan denied your request. The Plan says this copayment was applied based on the records provided by the physician 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 $40 copayment for outpatient mental health visits. 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 $40 copayment charged for physician services provided on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on November 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services 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 forthe medical services provided to you by an out-of-network provider on November 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from April 20, 2019 through April 28, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were informed you weren't responsible for the bill. You say that you want to know why you have to pay. 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 $330 per day, days 1-5 and $0 per day, days 6-90 for each in-network, medically necessary covered inpatient stay. You have been asked to pay $1,650 for the inpatient stay. ($330/day x first 5 days = $1,650). The inpatient stay falls within the "Inpatient hospital care" 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 inpatient stay provided from April 20, 2019 through April 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on January 8, 2020.You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that the comprehensive oral evaluation (D0150) is a necessity. You also say that the panoramic x-ray (D0330) is highly needed to make sure nothing is overlooked.The Plan denied your request. The Plan says these services exceed the frequency limitation in the benefit plan.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, comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on December 2, 2019 and your comprehensive oral evaluation and panoramic x-ray benefits have been exhausted.Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on November 13,
2019.
You asked the Plan to pay for the periodontal maintenance. You say that you get 4 cleanings each year and
every other one is periodontal, which is preventive treatment. You also say that this periodontal cleaning
happened to fall at the end of the year when your dental benefits with the other insurance ran out. The Plan
denied your request. The Plan says this service is 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.
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
periodontal maintenance provided on November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNFcare from August 6, 2019 through August 31, 2019 provided an in-network provider.You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted to the facility on July 16, 2019 through July 31,2019, for a total of 15 days. You were then admitted to the facility on August 6, 2019 through September 7, 2019. You did not start a new benefit period since only six (6) days had lapsed since you were discharged from the prior SNF stay. For July 16, 2019 through July 31, 2019, a total of 15 days, your EOC states, you are responsible for $0 copayment per day, days 1-20. For August 6, 2019 through August 10, 2019, a total of five (5) SNF days, you are asked to pay a $0 copayment. For August 11, 2019 through August 31, 2019, a total of twenty-one (21) SNF days, your EOC states that you are responsible for a $164 copayment per days, days 21-100, totaling $3,444. 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 SNF care from August 6, 2019 through August 31, 2019 provided an in-network provider.