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

We decided that the Plan does not have to pay for the amalgam - two surfaces, primary or permanent (D2150) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided October 16, 2020.
You asked the Plan to pay for the amalgam and local anesthesia. You say that you are entitled to four fillings per year and the service should be covered. The Plan denied your request. The Plan says the services as provided are not covered under your 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 amalgam - two surfaces, primary or permanent (D2150) and local anesthesia in conjunction with operative or surgical procedures (D9215) provided October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services provided on October 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the debridement services provided on October 16, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 12, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the laboratory services was not filed until October 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endocrinology visit.

You asked the Plan to waive the copayment for specialist visit. You say that this is in regard to care associated
with an emergency room visit and subsequent hospital admission. The Plan denied your request. The Plan says
the copayment 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30
copayment for in-network specialist visit.

You have been asked to pay $30 copayment for specialist visit. Specialist visits fall within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 an endocrinology visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on July 10, 2020.
You asked the Plan to pay for the physician's 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
physician's 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 physician's services that you provided on July 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis with sleeve provided on September 8, 2020.
You asked the Plan to pay for the orthosis and sleeve. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that knee orthoses are covered when the coverage criteria in the applicable LCD are met. 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 orthosis and sleeve. Our reviewer says that the requested knee orthosis is not medically reasonable and necessary in this case. Our physician reviewer found that there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthosis and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis with sleeve provided on September 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you have problems with balance and cannot stand properly. The Plan denied your request. The Plan says your needs are custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our physician reviewer found that you were admitted to the acute hospital with recurrent falls. You are at a contact guard to minimal assist level for mobility and transfers. There are no identifiable skilled nursing services. You would likely benefit from skilled therapy services. However, the documentation does not support that continued skilled therapy or nursing services are necessary on a daily basis in an inpatient facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for polycarbonate lens (V2784) deluxe frames (V2020) vision supply, accessory and/or service component of another (V2797) lenses, single vision (V2100) provided October 23, 2020.
You asked the Plan to waive the copayment for the vision services. You say that the plan covers $99 for eye exams and the deduction of $24 for responsibility makes no sense. You do not agree and refuse to pay. The Plan denied your request. The Plan says this claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 any amount over $100 the retail price for the purchase and fitting of eyeglasses (frames and lenses) or contact lenses for Vision care. You have been asked to pay $114.40 copayment for the vision services. The provider billed $238 for the total services. For the frames and lenses the provider billed $218.00. The plan allowed $123.60 for the frames and lenses and there was also a discount applied of $63.60. CPT code V2797 is not covered under the plan benefits. The vision services fall within the Vision 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 polycarbonate lens (V2784) deluxe frames (V2020) vision supply, accessory and/or service component of another (V2797) lenses, single vision (V2100) provided October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and three additional intraoral periapical x-rays provided on October 12, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you were advised that this provider was in-network and the services would be covered. The Plan denied your request. The Plan says benefits for these services have been satisfied and the frequency limitation has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received two first intraoral periapical x-rays on October 12, 2020, one of which was covered by the Plan, and your intraoral x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and three additional intraoral periapical x-rays provided on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient hospital facility on July 1, 2020.
You asked the Plan to waive the copayment for the lab services. You say that your doctor ordered this bloodwork for you prior to a visit. You said that previous claims for lab services were always paid in full. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for lab services at an outpatient hospital facility. You have been asked to pay a $40 copayment for the lab services. Records show that you received these lab services at an outpatient hospital facility. 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 lab services you received at an outpatient hospital facility on July 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit.

You asked the Plan to waive the copayment for the specialist visit. You say that you had a colonoscopy and upper gastrointestinal endoscopy. You say that normally you would get results the same day, but because the office was so busy, you had to return a week later for results. You say that you should not have to pay a copayment just to get test results. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it reviewed the medical records from this date of service and you did not just receive test results, but you also received a full office visit.

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 $50 copayment for specialist visits.

You have been asked to pay a $50 copayment for the specialist visit. We also reviewed your medical records from this date of service. In addition to reviewing the results of your procedures, the medical records clearly indicate that you also received counseling on the medications you were taking as well as a full review and physical exam of your body systems. That is why the office visit applies. 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 specialist visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for amalgam (D2150) and pulp cap (D3120).

You asked the Plan to pay for amalgam and pulp cap. You say that you called the Plan and were told that this provider was in-network. The Plan denied your request. The Plan says services were rendered by an out-of-network provider and prior authorization was not obtained. There are providers with your local area that are contracted with 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. The Plan covers amalgam and pulp cap when the services are rendered with and in-network provider.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of amalgam and pulp cap have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these 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 amalgam (D2150) and pulp cap (D3120).

Your complaint about the potential misinformation you received 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray transportation (R0070) and set-up (Q0092) provided on September 13, 2020.
You asked the Plan to pay for x-ray transportation and set-up. You say that this should be covered. The Plan denied your request. The Plan says this cannot be separately billed from the SNF stay.
The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, the technical component representing the procedure itself, including any associated transportation and setup costs, is subject to consolidated billing and must be included on the SNF's Part A bill for the resident's covered stay rather than being billed separately under Part B. We looked at the file and Medicare rules. The record shows that the enrollee was a SNF resident at the time of service, meaning technical components of services, including transportation and set up, cannot be separately billed from the SNF stay. Based on this information, we decided that Medicare rules for coverage of x-ray transportation have not been met. Therefore, we decided that the Plan does not have to pay for x-ray transportation (R0070) and set-up (Q0092) provided on September 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revascularization treatment to the lower extremities to
be provided by an OON provider.

You asked the Plan to pre-approve revascularization treatment to the lower extremities. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can
be provided by a network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
revascularization treatment to the lower extremities to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on May 5, 2020.
You asked the Plan to waive the coinsurance for braces. You say that the braces did not work for you. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for braces. The total allowed amount is $3,360.50. The total amount you are being asked to pay is $672.10 ($3,360.50 x 20% = $672.10). Braces fall within the durable medical equipment/in-network 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 durable medical equipment provided by a participating provider on May 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on October 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says authorization for out-of-network services 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 had network providers available to 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 wound care services provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HHS, for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee does not require any specific skilled services at this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not appear to be truly homebound. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. As such, HHS are not shown to be 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve HHS, for the enrollee.