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

We decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on October 31, 2019.You asked the Plan to pay forthe dental service. You say that you requested the panoramic x-ray you received from a previous provider. You say they could not provide it. You also say that you would not have gotten the x-ray if you knew it would not be covered.The Plan denied your request. The Plan says the frequency limit has been exceeded.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 panoramic x-rays are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for the panoramic x-ray that you received on February 26, 2019.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray (D0330) provided on October 31, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required and porcelain or ceramic crown provided on October 7, 2019.You asked the Plan to pay forthe core buildup and crown. You say that you cannot afford to pay for the dental work you need for your crown.The Plan denied your request. The Plan says you were advised that this provider was out-of-network prior to the services being rendered. The Plan also says that you wereinformed that you may be balance billed for these services.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 required to pay the difference between the billed and allowed amount because the provider is out-of-network. The records show that the provider billed $292.00 for the core buildup, the allowed amount was $114.00 and the Plan paid at 100% of the allowed amount, leaving a balance of $178.00. The provider billed $1296.00 for the crown, the allowed amount was $595.00 and the Plan paid 100% of the allowed amount, leaving a balance of $701.00. The provider is billing you for the total amount of $879.00.Therefore, we decided that the Plan does not have to pay forthe core buildup, including any pins when required and porcelain or ceramic crown provided on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided to enrollee on January 10, 2019.You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says Medicare pays for limited number of Part B services via telehealth services.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.The enrollee received lab services as identified by procedure codes 0033U-90, 81432-90, and 81437-90A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the lab testing provided to enrollee on January 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 83735, 80053, and 83880 provided on August 31, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 83735, 80053,and 83880 are not supported in the medical record. Specifically, these codes have a professional component/technical component indicator of "6". These services are reported under the clinical laboratory code with modifier 26. The documentation supports that the services are not payable as billed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 83735, 80053,and 83880 provided on August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoptic and/or pleoptic training, with continuing medical direction and evaluation (CPT Code 92065) provided from January 2, 2019 through June 24, 2019.You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this service is not covered under Medicare or the Health Plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Your EOC clearly states, the limitations and exclusions below apply to your additional vision benefit: Orthoptics or vision training and any associated supplemental testing.
Therefore, we decided that the Plan does not have to pay for orthoptic and/or pleoptic training, with continuing medical direction and evaluation (CPT Code 92065) provided from January 2, 2019 through June 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on September 11, 2019.You asked the Plan to pay fortheproblem focused limited oral evaluation. You say that you were not aware of the dental benefits guide.The Plan denied your request. The Plan says no more than one emergency exam in any 12-month period is allowed.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, routine oral exams are limited to 1 standard exam per 6-month period. The record shows that you received a limited oral evaluation on August 27, 2019 and your routine oral exams benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation provided on September 11, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric diagnostic evaluation with medical services provided on September 3, 2018.You asked the Plan to pay forthe psychiatric diagnostic evaluation. You say that you did not receive proper notice of this enrollee's benefit determination which is why this was filed untimely. You also say that the physician provided medically necessary services to this enrollee in good faith.The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the Plan within 12 months or 1 calendar year from the date when the services were rendered. The Plan also says that the claim was received on October 4, 2019, which is past the allowed 12 month timeframe.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the psychiatric diagnostic evaluation was not filed until October 4, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe psychiatric diagnostic evaluation with medical services provided on September 3, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing rendered to the enrollee on October 16, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal wasrequested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe genetic testing rendered to the enrollee on October 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you've had bladder incontinence for years and have to wear large pads in the day and diapers at night.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentforthe SNF stay provided from November 1, 2018 through November 20, 2018.You asked the Plan to waive the copayment forthe SNF stay. You say that you were informed the provider was in-network and that you could stay for 20 days. You say that you appeal the 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 $0 copayment each day for days 1 to 20 and a $160 copayment each day for days 21 to 62 at an in-network provider.You have been asked to pay an $800 copayment for the SNF stay. The SNF stay falls within the "Skilled Nursing Facility (SNF) 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 forthe SNF stay provided from November 1, 2018 through November 20, 2018
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. 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 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 forthe medical services provided on August 9, 2019 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 periodontal maintenance provided on November 1, 2018.You asked the Plan to pay for the periodontal maintenance. You say that you have had periodontal services 3 times a year for the last 10 years which has been very effective for you. You also say that you mailed in an appeal request on January 3, 2018 and never received a response.The Plan denied your request.The Plan says this service is only allowed twice in a benefit period.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, routine preventive teeth cleanings are limited to a maximum of 2 per calendar year. The record shows that you received cleanings on February 5, 2018 and June 19, 2019 and your routine preventive cleaning benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on November 1, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora FreeStyle Libre glucose monitor purchased on August 23, 2019.You asked the Plan to pay fora FreeStyle Libre glucose monitor. You say that you did not realize this was out of network.The Plan denied your request. The Plan says this brand of glucose monitor is not covered by the Plan.The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.We looked at the file and Medicare rules. Specifically, the brand of glucose monitor purchased is not covered by the Plan. The documentation submitted did not include a reason why it is medically necessary to use this 
brand over the Plan's preferred Plan. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre glucose monitor have not been met.Therefore, we decided that the Plan does not have to pay fora FreeStyle Libre glucose monitor purchased on August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D brush biopsy provided to the enrollee on July 23, 2019.
You asked the Plan to pay for the WATS 3D brush biopsy. The Plan denied your request. The Plan says this service has not proven its medical efficacy.
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 pay for the WATS 3D brush biopsy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the American Society for Gastrointestinal Endoscopy (ASGE) has included WATS 3D in its Standards of Practice Committee's guideline for the screening and surveillance of Barrett's esophagus. However, in this enrollee's case, available records do not support high suspicion of Barrett's esophagus to warrant the WATS 3D service as medically 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 the WATS 3D brush biopsy have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D brush biopsy provided to the enrollee on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion and urinalysis to be provided by an out of network (OON) provider.You asked the Plan to pre-approve a second opinion and urinalysis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.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-approvea second opinion and urinalysis to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine vision services provided on January 25, 2019.You asked the Plan to pay for routine vision services. You say that this should be a Medicare covered vision The Plan denied your request. The Plan says routine vision services are not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. The medical records confirm you had a routine vision visit, which is not a covered benefit with the Plan or with Medicare.Therefore, we decided that the Plan does not have to pay for routine vision services provided on January 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on August 22, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you believed this would be free. The Plan denied your request. The Plan says that the claim processed 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 15% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 15% coinsurance for the injection. The injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Prolia injection provided on August 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone density scan provided on October
11, 2019.
You asked the Plan to waive the copayment for the bone density scan. You say that you were told there would
not be a copayment for the scan. The Plan denied your request. The Plan says you have been charged the
correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15
copayment for Medicare-covered x-rays and ultrasounds.
You have been asked to pay a $15 copayment for the bone density scan. The bone density scan falls within
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the bone
density scan is a type of x-ray.
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 bone density scan provided on October 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Megestrol Ac Tab 40mg.You asked the Plan to pre-approve Megestrol Ac Tab 40mg. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the healthplan, therefore self-administered drugs do not meet the criteria for coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Megestrol Ac Tab 40mg.Benefits for Megestrol Ac Tab 40mgmay 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided, on February 8, 2019.
You asked the Plan to pay for the comprehensive oral evaluation. You say that your dental coverage did not end until November 30, 2019. You also say that you were covered for this claim because your dental coverage was active. The Plan denied your request. The Plan says these services were rendered prior to your plan's start date on March 1, 2019.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided on February 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on September 30, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you disagree with the charges because you did not receive a vaccine.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment per visit for laboratory tests. You have been asked to pay the allowed amount of $4.70, which is less than the $10 copayment for laboratory services. Laboratory services fall 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 forlaboratory servicesprovided on September 30, 2019.