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

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120), therapeutic parenteral drugs (D9612), and comprehensive oral evaluation (D0150), and to pay more for the panoramic x-ray (D0330), two extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), and three subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x3) provided on April 15, 2021 by an OON provider.
You asked the Plan to pay for the fixed partial denture sectioning, therapeutic parenteral drugs, and comprehensive oral evaluation, or pay more for the panoramic x-ray, extractions, and deep sedation/general anesthesia. You say that the dental office did not verify eligibility prior to rendering the services. The Plan denied your request. The Plan says the fixed partial denture sectioning and therapeutic parenteral drugs are not covered benefits. The Plan says that your comprehensive oral evaluation benefit has been exhausted. The Plan also says that the claim paid correctly up to the annual maximum allowable for OON providers for the panoramic x-ray, extractions, and deep sedation/general anesthesia.
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 fixed partial denture sectioning (D9120) and therapeutic parenteral drugs (D9612) are not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on October 9, 2018 and your comprehensive oral evaluation (D0150) benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120), therapeutic parenteral drugs (D9612), and comprehensive oral evaluation (D0150), and to pay more for the panoramic x-ray (D0330), two extractions (D7210 x2), first 15 minutes of deep sedation/general anesthesia (D9222), and three subsequent 15 minute increments of deep sedation/general anesthesia (D9223 x3) provided on April 15, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation, per site, (D7953 x 8).
You asked the Plan to pre-approve the dental services. You say that you were approved for 9 extractions. You also say that you would like to know if you can still have a full denture. The Plan denied your request. The Plan says bone replacement graft for ridge preservation, per site, 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 bone replacement graft for ridge preservation, per site, is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation, per site, (D7953 x 8).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43235) provided on March 1, 2021, by an out-of-network provider.
You asked the Plan to pay for an esophagogastroduodenoscopy. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 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 an esophagogastroduodenoscopy (43235) provided on March 1, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on April 15, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you agreed to a much lower monthly cost and do not agree with the charges. 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 20% coinsurance for DME and related supplies. You received DME and related supplies on April 15, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $525.42 and 20% of that is $105.08. You have been asked to pay the total coinsurance amount of $105.08 for DME and related supplies. DME and related supplies fall within the DME and related 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 coinsurance for DME and related supplies provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve these OON services. You say that you do not agree with the only two options provided by the network specialist. 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-approve a second opinion to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 18, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 testing. Our reviewer says that the equested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that cardiac gene variant testing has limited clinical application at present and is occasionally useful in rare familial inherited cardiac conditions. Current guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (computed tomography calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. Cardiac gene variant testing is not currently recommended for general risk stratification. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on November 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation mileage.

You asked the Plan to provide coverage for additional routine transportation mileage. The Plan denied your request. The Plan says your Plan benefit only allows fifty (50) miles of driving distance.

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. The file shows that the requested trip with the shortest route is 59.6 miles and you will have exceeded your benefit mileage limit. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation mileage
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and the
administration provided from January 6, 2021, to April 28, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs and the administration. You say that
you pay a lot of money and do not understand why all of a sudden the charges are not being covered when you
had pre-approval. 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 20%
coinsurance for Medicare Part B drugs and the administration.

You received Medicare Part B drugs and the administration from January 6, 2021, to April 28, 2021. Therefore,
you are responsible to pay your share of the cost-sharing charges. Please see the chart below.

Date of Service Service Codes Allowed Amount Amount You Owe

1/6/2021 J0885, 96372 $212.51 $42.50
3/1/2021 J0885, 96372 $176.52 $35.31
3/16/2021 J0885, 96372 $158.50 $31.71
4/28/2021 J0885, 96372 $153.96 $30.79

The total amount you owe is: $140.31.

You have been asked to pay the total coinsurance amount of $140.31 for Medicare Part B drugs and the
administration. Medicare Part B drugs and the administration fall 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 Medicare Part B drugs and the
administration provided from January 6, 2021, to April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is undergoing an elective left reverse total shoulder arthroplasty. The planned procedure is not listed on the Centers for Medicare & Medicaid Services Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate sedation services (99157).

You asked the Plan to pre-approve the moderate sedation. You say that the sedation is for a tooth extraction. The Plan denied your request. The Plan says sedation for a simple extraction 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 pre-approve moderate sedation services (99157).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6241) for teeth 3, 4, and 14, and retainer
crowns (D6751) for teeth # 2, 5, 13, and 15.
You asked the Plan to pre-approve the fixed partial dentures. You say that you feel that the services should be
covered. You also say that you have not use your allowance. The Plan denied your request. The Plan says
pontics are not listed as covered services. The Plan also says retainer crowns are not listed as covered services
either.
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 pontics and retainer
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve pontics (D6241) for teeth 3, 4, and 14, and retainer crowns (D6751) for teeth # 2, 5, 13, and 15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six simple extractions and an immediate maxillary partial denture.

You asked the Plan to pre-approve the extractions and maxillary partial denture. You say that the provider's office recommended you receive these services. The Plan denied your request. The Plan says your extractions benefit has been exhausted for the plan year. The Plan also says that the maxillary partial denture 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, dentures are not among those covered under this benefit. The contract says that extractions are limited to 1 procedure per year.

The record shows that you were approved to receive 1 surgical extraction on June 17, 2021, and your extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve six simple extractions and an immediate maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
You asked the Plan to pre-approve the pontic and retainer crowns. You say that the replacement of the enrollee's fixed partial denture was recommended to prevent the formation of decay and prevent further loss of tooth structure. The Plan denied your request. The Plan says these services are not covered under the enrollee's 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. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) and two retainer crowns (D6740 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve Cologuard testing.

You asked the Plan to pre-approve the requested testing. You say that your provider suggested the test. The Plan denied your request. The Plan says you do not meet the guidelines for the testing.

The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is only covered under certain medical indications. 

We looked at the file and Medicare rules. The medical records provided indicate that you are symptomatic due to small bowel issues. The Cologuard testing is only covered for those who are without symptoms. Based on this information, we decided that Medicare rules for coverage of the requested testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard testing.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $125 copayment for ambulance transport provided to the enrollee on March 21, 2021.
You asked the Plan to waive this copayment. You say that this was a transport from one facility to another and no one told the enrollee there would be a copayment. The Plan denied your request. The Plan says this copayment was charged based on 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). The enrollee's contract with the Plan clearly says that enrollees must pay $125 copayment for each one-way ambulance transport. 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 $125 copayment for ambulance transport provided to the enrollee on March 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two guided tissue regenerations (D4266 x2) and two bone replacement grafts for ridge preservation (D7953 x2).

You asked the Plan to pre-approve the guided tissue regenerations and bone replacement grafts. You say that you would like to appeal these services. The Plan denied your request. The Plan says these procedures are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two guided tissue regenerations (D4266 x2) and two bone replacement grafts for ridge preservation (D7953 x2).