Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee injection provided on January 16,
2020.
You asked the Plan to waive the copayment for the knee injection. You say that you did not have outpatient
surgery and you do not think you should be billed for it. 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 $100
copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory
surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.
You have been asked to pay a $100 copayment for the knee injection. The knee injection falls within the
"Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers" benefit category. The record shows the knee injection is considered a surgical procedure.
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 knee injection provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.
You asked the Plan to pay for foot orthotics. You say that you were told that you needed to submit a
prescription with your orthotic claim. You say that your podiatrist knew you had a leg length discrepancy and
thought that it may have increased. You stated that you have chronic pain in your back that was relieved eight
or nine years ago when you received a lift for your shoe. You say that it was a necessity to have the lift
installed in your shoe. You stated that you do not have the money to pay for supportive shoes and you want to
make sure you can exercise both physically and mentally. The Plan denied your request. The Plan says this
item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT chest imaging for coronary calcium scoring.
You asked the Plan to pre-approve the coronary calcium scoring. You say that this imaging is necessary to
determine your risk. The Plan denied your request. The Plan says this is a screening service and is not useful
for therapeutic decision-making.
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 the coronary calcium scoring. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has a history of high blood pressure, high cholesterol and SVT. The
enrollee reported dyspnea on exertion late in 2019, for which a stress echocardiogram was performed. That test
showed no evidence of ischemic changes and was deemed negative. It is unclear how the requested coronary
calcium CT scan would affect the patient's diagnoses or management. The documentation does not support that
the requested test is medically necessary or reasonable.
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 coronary calcium scoring have not been met. Therefore, we decided that the
Plan does not have to pre-approve CT chest imaging for coronary calcium scoring.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided on November 13, 2019.
You asked the Plan to waive the copayment for a duplex scan. You say that you were not informed of the charges ahead of time and would not have received the service if you had known the cost. 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 $100 copayment for diagnostic procedures and tests provided in an outpatient hospital facility. You have been asked to pay a $100 copayment for a duplex scan. A duplex scan falls 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 for a duplex scan provided on November 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from the specialized care in the LTACH setting. The Plan denied your request. The Plan says an LTACH is not able to offer specialized care and this enrollee's needs can be met in a skilled nursing facility (SNF).
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an acute care hospital for cardiac arrhythmias leading to a cardiac arrest and acute kidney injury. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for continuous positive airway pressure (CPAP) device (E0601) provided on January 8, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that the new device was a replacement to a previously purchased CPAP device that was no longer functioning and are requesting that the Plan reconsider the cost share. 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). The original machine was purchased on May 18, 2015 and the manufacture warranty of 12 months terminated on May 18, 2016 after that you would repair and bill the insurance company. They replace machines every five (5) years. As per correspondence with the DME provider, you did not want the original machine repair and a new machine was requested by you on October 28, 2019. Review of the file shows that you had the CPAP device on January 8, 2020. You are asked to pay 20% coinsurance for the DME. Your EOC states enrollees must pay 20% coinsurance for DME and related supplies. 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 continuous positive airway pressure (CPAP) device (E0601) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 15, 2020.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you did not provide documentation to verify.
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 sent out a reimbursement request reject letter to you requesting a copy of itemized charges to complete the processing of reimbursement. Therefore, we decided that the Plan does not have to pay for the dental services provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive exam (D0150) provided on January 29, 2020.
You asked the Plan to pay for the dental services. You say that you do not see that the plan has paid for this
service before. The Plan denied your request. The Plan says you exhausted your benefit frequency limit.
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 frequency limit, because you had this service on January 9, 2019. Your EOC states,
for D0150 - comprehensive exam (for a new patient, or an established patient after 3 or more years of inactivity
from dental treatment)- one (1) procedure every three (3) plan years. Therefore, we decided that the Plan does
not have to pay for comprehensive exam (D0150) provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 24,
2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
he Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from June 6, 2019, to
December 19, 2019.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these are
not covered services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the chiropractic services you received from June 6, 2019, to December
19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 20, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says progress notes from the ordering provider were not submitted.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided on
January 31, 2020.
You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like
reconsideration because this supply is medically necessary. The Plan denied your request. The Plan says the
documentation submitted did not indicate the provider discussed the need for the billed supply code.
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 shoulder elbow wrist hand orthosis. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found there is no documentation of a medical condition involving the shoulder
that requires an orthosis.
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 shoulder elbow wrist hand orthosis have not been met. Therefore, we
decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided on
January 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic images (D0350 x 4), the
crown (D2740) and core build up (D2950) for tooth # 15, the topical application of fluoride varnish (D1206),
the drugs or medicaments (D9630), the periodontal scaling and root planing (D4341 x 4), the gingival irrigation
(D4921 x 4), the oral hygiene instructions (D1330), and the unspecified periodontal procedure (D4999 x 4)
provided on January 10, 2020 by the out of network provider.
You asked the Plan to pay for the 2D oral or facial photographic images, the crown and core build up for tooth
# 15, fluoride, medication, and periodontal services. You say that the provider in this case is in network
according to the Plan's website. You say that you are doing your best to find in network providers and getting
authorizations when needed as you are on a limited income. You also say that the in network location is further
away from you. The Plan denied your request. The Plan says the 2D oral or facial photographic images, the
crown and core build up, fluoride, medication, and periodontal services are not covered 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, the dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D
oral or facial photographic images (D0350 x 4), the crown (D2740) and core build up (D2950) for tooth # 15,
the topical application of fluoride varnish (D1206), the drugs or medicaments (D9630), the periodontal scaling
and root planing (D4341 x 4), the gingival irrigation (D4921 x 4), the oral hygiene instructions (D1330), and
the unspecified periodontal procedure (D4999 x 4) provided on January 10, 2020 by the out of network
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for full mouth debridement crown, and core buildup (D4355,
D2740, and D2950) provided on December 5, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the services are not covered under Medicare or the
Health 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. Your EOC does not provide a benefit for full mouth debridement.
Your EOC provides a benefit for one crown per calendar year. The Plan has approved payment of one of the
two crowns you had for calendar year 2019. You do not meet the conditions for approval of full mouth
debridement or a second crown for the calendar year 2019. The requested items/services are not a covered
benefit under Medicare and your Plan. Your request is still unable to be approved. Therefore, we decided that
the Plan does not have to pay for full mouth debridement crown, and core buildup (D4355, D2740, and D2950)
provided on December 5, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for a bronchoscopy provided on February 27, 2020.
You asked the Plan to pay for the bronchoscopy. The Plan denied your request. The Plan says the services
rendered require 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 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 a bronchoscopy provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided
on March 18, 2020.
You asked the Plan to pay for the dental services. You say that the prior specialist examined the incorrect tooth
on January 20, 2020 which caused you to seek out another specialist. The Plan denied your request. The Plan
says you exhausted your benefit frequency limit.
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. You exhausted your benefit frequency limit, because you had this
service on January 6, 2020. Your EOC states, D0140 - limited exam to evaluate a problem - one (1) procedure
per plan year. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem
focused (D0140) provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on February 17, 2020.
You asked the Plan to pay for the services. You say that the provider told you that they accepted your
insurance. The Plan denied your request. The Plan says a prior authorization was not requested.
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 you by an out-of-network provider on
February 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 24, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you had to be transferred due to the hospital not being able to perform a procedure. 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on November 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance
provided on January 30, 2020.
You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that you were
under the impression that your plan covered 2 cleanings per year. You also say that you were not informed that
they had to be 6 months apart. The Plan denied your request. The Plan says these services exceed the frequency
limitations allowed in your 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, oral exams and cleanings are each
limited to up to 1 visit every six months. The record shows that you received an oral exam and periodontal
maintenance on August 13, 2019 and your oral exams and cleanings benefits were then exhausted for the time
period. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and
periodontal maintenance provided on January 30, 2020.