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

We decided that the Plan does not have to pay for physician's services provided on March 5, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 physician's services provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274) and topical application of fluoride varnish (D1206) provided on January 21, 2020.
You asked the Plan to pay for the bitewings and topical application of fluoride varnish. You say that your member booklet states that the Plan would pay for one fluoride treatment and one x-ray each year. The Plan denied your request. The Plan says these services are not covered by the 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 pay for the bitewings (D0274) and topical application of fluoride varnish (D1206) provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the power wheelchair and mounting hardware provided on September 30, 2019.
You asked the Plan to waive the coinsurance for these items. 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay a 20% coinsurance for these items. These items fall within the durable medical equipment 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 the power wheelchair and mounting hardware provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 16, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers 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 physician's services provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283), hot or cold pack application (97010), and a therapeutic procedure (97110) provided by a chiropractor on January 20, 2020.
You asked the Plan to pay for electrical stimulation, hot or cold pack application, and a therapeutic procedure. You say that these services were previously covered. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283), hot or cold pack application (97010), and a therapeutic procedure (97110) provided by a chiropractor on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 23, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says that the 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 psychotherapy services provided on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the continuous glucose monitor sensors provided from January 29, 2020 to March 20, 2020.
You asked the Plan to waive the cost share for the sensors. You say that the CGM supplies are not durable medical equipment. The Plan denied your request. The Plan says you were charged this cost share 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 20% cost share for Durable Medical Equipment. You have been asked to pay 20% cost share for the cost share for the sensors. the cost share for the sensors falls within the Durable Medical Equipment 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 8, 2020.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this service
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 January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular
denture provided on February 15, 2020.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that
you were under the impression that these services were covered by your Plan because you had received an
approval letter. You also say that you are on a limited income and are unable to afford the payment. The Plan
denied your request. The Plan says you have exceeded your maximum 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 Plan offers a $1,000 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. At the time the Plan provided the
authorization, you had not used any of your $1,000 yearly maximum benefit. The record shows that you met
the annual maximum benefit on February 15, 2020 and your annual maximum benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the complete maxillary denture and complete
mandibular denture provided on February 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital care provided on January 6, 2020.
You asked the Plan to pay for the outpatient hospital care. The Plan denied your request. The Plan says the provider is not in-network and there is no authorization on file.
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 outpatient hospital care provided on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 3 fillings provided on February 18, 2020.
You asked the Plan to pay for the dental services. You say that page 17 of your dental coverage states that fillings are a covered service. The Plan denied your request. The Plan says fillings are covered under the optional supplemental dental rider coverage only. The Plan also says you were not enrolled in the optional supplemental dental rider when you received 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, the fillings you received are not among those covered under this benefit. The record shows you were not enrolled in the optional supplemental dental rider at the time you received the services which would have allowed for the services to be covered. Therefore, we decided that the Plan does not have to pay for 3 fillings provided on February 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 23, 2020.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the copayment applies.
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 $325 copayment for Medicare-covered ambulance services per trip. You have been asked to pay a $273.13 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services per trip benefit category. This means that you have been asked to pay less than 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 transport provided on January 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage (A0425)provided October 28, 2019.
You asked the Plan to pay for the BLS non-emergency ambulance. You say that the enrollee is immobile so an ambulance was required to take him to the sleep disorder center. Please reconsider this claim as this appointment was necessary for his health. The Plan denied your request. The Plan says a physician's office is not a covered destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage (A0425)provided October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on January 8, 2020.
You asked the Plan to pay for the dental service. You say that you are appealing the balance of the charge for
your dental cleaning. You say that you were advised after your appointment that bitewings are not a covered
service. You also say that your brochure does not specifically say that they are not covered. The Plan denied
your request. The Plan says the bitewing x-rays 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, the bitewing x-rays are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing xrays
(D0274) provided on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional intraoral periapical x-rays and one
additional resin-based composite provided on January 21, 2020.
You asked the Plan to pay for the two additional intraoral periapical x-rays and one additional resin-based
composite. You say that you contacted the Plan prior to having these services rendered and were told the
treating provider was in network with your plan. You also say that the receptionist contacted your plan and was
told that you would be covered. The Plan denied your request. The Plan says the benefits for these services
have been satisfied and the frequency limitations have 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, intraoral x-rays are limited to one
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on January 21,
2020, which the Plan paid for, and your intraoral x-rays benefit has been exhausted. The Plan contract also says
that restorations are limited to two procedures per calendar year. The record shows that you received three
resin-based composites on January 21, 2020, the Plan paid for two, and your restorations benefit has been
exhausted. Therefore, we decided that the Plan does not have to pay for the two additional intraoral periapical
x-rays and one additional resin-based composite provided on January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tuberculosis test (86480) provided December 10, 2019.
You asked the Plan to pay for the Tuberculosis test. You say that 86480 is not a dx driven code and therefore,
can be billed with any dx per Medicare guidelines. Please review and reprocess this claim appropriately. The
Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that tuberculosis testing as a screening test is a noncovered
service in the absence of a diagnosis.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Tuberculosis test have not been met. Therefore, we decided that the Plan does not have to pay
for the Tuberculosis test (86480) provided December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the crown (D2740) for tooth # 19, the
comprehensive oral exam (D0150), prophylaxis (D1110), and the complete series of x-rays (D0210) provided
from January 21, 2020 to February 6, 2020.
You asked the Plan to pay the full amount for the dental services. You say that the dental office called on
January 21, 2020 for authorization of the services that you would receive later that day. You say that the office
advised the services would be covered with a $0 copay. You say that you returned to receive more services on
February 6, 2020. You also say that you feel that the dental office was misinformed by your insurance and
should therefore be the insurance company's responsibility. The Plan denied your request. The Plan says there
is an annual allowance of $1,000 for preventive and supplemental dental services that you receive. The Plan
says that the annual allowance has been exceeded. The Plan also says that you are responsible for any amount
above the annual allowance.
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 annual allowance of $1,000 for
dental services that you receive has been exceeded. Therefore, we decided that the Plan does not have to pay the full amount for the crown (D2740) for tooth # 19,
the comprehensive oral exam (D0150), prophylaxis (D1110), and the complete series of x-rays (D0210)
provided from January 21, 2020 to February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the remaining amount for the oral exam (D0120) and prophylaxis (D1110) provided on February 18, 2020 by out of network provider.
You asked the Plan to pay the remaining amount for the dental services. You say that the dental services you received should be covered at 100% according to the Evidence of Coverage and dental rider. You say that you should not be billed anything outside of what the insurance paid. You also say that you would like the remaining balance to be resolved. The Plan denied your request. The Plan says for dental services covered under the plan, you may still be billed by an out of network provider for any amount greater than the payment made by the plan to the provider.
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 the services are listed as covered, you may still be billed by an out of network provider for any amount greater than the payment made by the plan to the provider. Cost share amounts are a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay the remaining amount for the oral exam (D0120) and prophylaxis (D1110) provided on February 18, 2020 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction and collect and apply blood product
provided on February 20, 2020.
You asked the Plan to pay for the extraction. You say that you would like a medical opinion of the denial of the
jaw infection and the extraction of tooth #2. You also say that you had been warned that such dental problems
could arise from the medical treatment of your osteoporosis condition. The Plan denied your request. The Plan
says the surgical removal services provided are non-covered services according to your benefits.
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 when they are received by an oral surgeon. The contract clearly states
that surgical extractions which are typically performed by an oral surgeon are not covered. Therefore, we
decided that the Plan does not have to pay for the surgical extraction and collect and apply blood product
provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy provided on February 13, 2020.
You asked the Plan to pay for the endodontic therapy. You say that a Plan representative told you that you had
$2,000 coverage for dental care. You also say that your insurance card did not state specific payment guidelines
or processing policies for specific procedure codes. The Plan denied your request. The Plan says this service is
not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
endodontic therapy provided on February 13, 2020.
Your complaint about being misled by the Plan is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that you need a replacement power wheelchair. The Plan denied your request. The Plan says you do not have a mobility limation due to a neurological condition, myopathy, or congenital skeletal deformity.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a Group 3 power wheelchair and accessories.