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

We decided that the Plan does not have to pay for the removal of torus palatinus (D7472), the removal of torus mandibularis (D7473 x 2), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 3), the therapeutic parenteral drug (D9610), and the collection of autologous blood concentrate product (D7921) provided on November 4, 2020.
You asked the Plan to pay for the dental services. You say that you did not know that the provider was not a Medicare doctor. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a provider that has opted out of Medicare.
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 record shows that regardless of the provider's Medicare status, the services would not be covered as they are not listed as covered services. Therefore, we decided that the Plan does not have to pay for the removal of torus palatinus (D7472), the removal of torus mandibularis (D7473 x 2), the initial 15 minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223 x 3), the therapeutic parenteral drug (D9610), and the collection of autologous blood concentrate product (D7921) provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on August 10, 2020.
You asked the Plan to pay for nursing facility care. You say that medical records and proof of timely filing are attached for retro authorization. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (CPT code D7210).
You asked the Plan to pre-approve the dental services. You say that your tooth is infected, you have inflammation, you cannot eat properly, and your health is compromised due to diabetes. The Plan denied your request. The Plan says you exhausted your 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. You exhausted your benefit because you had this service performed previously. Your supplemental dental contract states that CPT Code D7210 is covered one (1) per Lifetime, per patient per tooth. Therefore, we decided that the Plan does not have to pre-approve surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (CPT code D7210).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one hundred sixty (160) additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you require additional routine transportations trips to attend medical appointments. The Plan denied your request. The Plan says there are no additional trips available.
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. We looked at your request, the records in the case file, and the rules. You have exhausted your 2021 routine transportation benefit. The 61st trip and beyond is not a covered benefit. The health plan contract says up to sixty (60) one-way trips are covered per calendar year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-approve one hundred sixty (160) additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of impact ear wax provided on November 4, 2020.
You asked the Plan to pay for the removal of impact ear wax. You say that you were not aware that you needed a referral from your primary care provider to see an ear, nose and throat doctor. The Plan denied your request. The Plan says the services were not urgent or emergent and were provided by an out-of-network provider and were not authorized in advance by the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 removal of impact ear wax provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained, and the provider is non-contract.
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 subsequent nursing facility care provided on October 1, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the comprehensive oral evaluation (D0150), bitewing x-rays (D0274), the panoramic x-ray (D0330), the periodontal scaling and root planing (D4341 x 4), and the extraction (D7140) provided on October 1, 2020.
You asked the Plan to pay the full amount for the dental services. You say that your dentist said that your Plan told them that these services would be covered. You also say that you paid $595 for your part of the bill. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that you are responsible for the difference between the in-network fee schedule (INFS) and dentists' charged fees when visiting an out of network dentist. The Plan says that the comprehensive oral evaluation and bitewing x-rays are covered under the out of network benefit. The Plan also says that panoramic x-ray, periodontal scaling and root planing, and the extraction are 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, you pay 50% for dental services that you receive out of network. Additionally, the panoramic x-ray, periodontal scaling and root planing, and extraction are not among those covered under this benefit. The record shows that you are responsible for the billed amount of $966.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe physical therapy visits provided from June 30, 2020, to July 27, 2020.You asked the Plan to waive the copayments forthe physical therapy visits. You say that you were informed that you did not have any copayments for each visit because you haveMedicare. The Plan denied your request. The Plan says the claim for June 30, 2020 was reprocessed and reduced and you have been charged the correct copayment 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 $40 copayment for Medicare-covered physical therapy and speech therapy service. You have been asked to pay a $40 copaymentfor each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation 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 copayments forthe physical therapy visits provided from June 30, 2020, to July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 11, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for these tests is correct, because these tests are not
covered for screening purposes.
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 tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these
tests for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing
provided on August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from April 22, 2020, through May 10, 2020.
You asked the Plan to waive the copayment for inpatient hospital services. You say that the surgery was unnecessary, and you don't understand why a wound care provider needed to perform the surgery. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment per day (per Medicare-covered stay) for days 1-7. After the 7th day, the plan pays 100% of covered expenses.
You have been asked to pay a $1,400 copayment for inpatient hospital services. ($200/day x 7 days = $1,400). Inpatient hospital services fall 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 inpatient hospital services provided from April 22, 2020, through May 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray imaging (D0210), panoramic x-ray (D0330) and risk assessment (D0601) provided on October 27, 2020.
You asked the Plan to pay for the dental services. You say that you cannot afford the cost of these services. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan's supplemental dental 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 intraoral x-ray imaging (D0210), panoramic x-ray (D0330) and risk assessment (D0601) provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory testing provided on November 13, 2020.
You asked the Plan to waive the deductible for lab test. You say that this lab work should be covered under your annual wellness exam. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.
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 $500 deductible for lab test. At the time this claim was processed, $0 of the $500 deductible had been met. The allowed amount of the claim is $20.03, resulting in a deductible obligation of $20.03. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the time lab test was received on November 13, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory testing provided on November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on September 17, 2020.
You asked the Plan to pay for nursing facility care. You say that medical records and proof of timely filing are attached for retro authorization. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for nursing facility care provided by an out-of-network provider on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.
You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869), and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). You say that the enrollee needs this device for pain relief. The Plan denied your request. The Plan says there are not enough studies to show that the Vertiflex Superion device is better than regular treatment for the enrollee's problem.
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 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interlaminar spacer device is experimental. More research is needed to show safety and efficacy of the device. It is not medically needed in this case. Hardware is not needed. No instability has been shown. Open laminectomy is the gold standard for spinal stenosis treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) and Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) (22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician evaluation provided by an out-of-network provider on August 7, 2020.You asked the Plan to pay forthe physician evaluation. You say that there is a right to recover for services provided to eligible beneficiaries. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.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 providerwith the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe physician evaluation provided byan out-of-network provider on August 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
August 17, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the care was not prior authorized by the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 subsequent nursing facility care provided on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 8, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the diagnostic radiology services. 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 diagnostic radiology services provided on
October 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on July 23, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You submitted your bill for review. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 copayment for each in-and out-of-network one-way Medicare covered ground trip. You have been asked to pay $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride provided on July 23, 2020.