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

We decided that the Plan has to pay for the multiple services provided from January 15, 2021, to May 30, 2021.
You asked the Plan to pay for the multiple services. You say that you sent your primary insurance information to the Plan but all your claims denied. The Plan denied your request. The Plan says that multiple calls and correspondences were made but the Plan was only able to obtain some of the information from you.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan did not send the bills to the primary insurer, direct the providers to send the bills to the primary insurer, or pay for the services and submit bills to the primary insurer. Therefore, we decided that the Plan has to pay for the multiple services provided from January 15, 2021, to May 30, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), incomplete root canal (D3332), and pulp vitality tests (D0460) provided on April 29, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary, and the root canal could not be completed because the provider found a crack in your tooth. You feel this denial is harsh. The Plan denied your request. The Plan says pulp vitality tests and incomplete root canals are not covered by your dental benefit. In addition, you had a previous limited oral exam and have exceeded the frequency limitation for this 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 requested items or services are not among those covered under this benefit or are requested in a frequency that exceeds what is covered under this benefit. Per your contract with the Plan, an incomplete root canal and pulp vitality tests are not covered services under your dental benefit. Records also show that you had a previous limited oral evaluation that was provided on March 30, 2021, which was paid for by the Plan. The Plan can only cover one limited oral evaluation per year. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), incomplete root canal (D3332), and pulp vitality tests (D0460) provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80048, 83036) rendered by the out-of-network (OON) provider on June 15, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 the laboratory services (36415, 80048, 83036) rendered by the out-of-network (OON) provider on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs Acetaminophen, Aspirin, Celecoxib, Multivitamin, and Sitagliptin provided on April 27, 2021.
You asked the Plan to pay for self-administered drugs. You say that the performed procedure would not have the cost-saving benefit of recuperating at home without the medications at issue. The Plan denied your request. The Plan says rules for payment for self-administered drugs have not been met
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs Acetaminophen, Aspirin, Celecoxib, Multivitamin, and Sitagliptin provided on April 27, 2021.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network services provided on December 21, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 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 out of network physician services provided on December 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on January 4, 2021.
You asked the Plan to pay for the outpatient services. The Plan denied your request. The Plan says the provider failed to obtain authorization prior to services being rendered.
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 service 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 services provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on May 6, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and panoramic x-ray. You say that your health coordinator told you she made you an appointment with this provider. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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, comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on August 26, 2020 and your comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on May 6, 2021.shows that you received a comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) on August 26, 2020 and your comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and panoramic x-ray (D0330) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 27, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140) provided on March 11, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the extraction. You say that this extraction was an emergency and this surgical facility was recommended by your dentist. You also say that this treating provider was the only one who could fit you into that day's schedule. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective December 19, 2017, to December 19, 2021. The Plan also says that if you use a provider that has opted out of Medicare, you will not receive reimbursement.
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 covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the extraction (D7140) provided on March 11, 2021 by a Medicare opt out provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, head or brain provided on
April 4, 2021.
You asked the Plan to pay for computed tomography, head or brain. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for computed tomography, head or brain provided on
April 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids (V5261) purchased on October 20, 2017.
You asked the Plan to reimburse you for hearing aids. You say that you were told you would be reimbursed for your services. You also say that you paid off the hearing care provider and then contacted the Plan to submit a request but now it is denied. The Plan denied your request. The Plan says you submitted your reimbursement claim well after the 12-month timely filing limit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says that you are required to contact the Plan's hearing aid vendor to access the hearing aid benefit. The Plan contract also says you must submit your claim within twelve (12) months for medical services or items.
We looked at the file, and the Plan's rules. The records show that you submitted your reimbursement after the 12-month filing deadline. The records also show the hearing aids were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids (V5261) purchased on October 20, 2017.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on May 9, 2021, and May 10, 2021.

You asked the Plan to pay for the self-administered drugs. You say that while you were in the hospital the nurses gave you the prescribed drugs you normally take. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on May 9, 2021, and May 10, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided by an outpatient hospital facility on April 30, 2021.

You asked the Plan to waive the copayment for the lab services. You did not provide an argument in your appeal request. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for lab services at an outpatient hospital facility. 

The enrollee has been asked to pay a $25 copayment for the lab services. This means that 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 copayment for lab services provided by an outpatient hospital facility on April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851) provided on November 16, 2020.

You asked the Plan to pay for a knee orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

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 a knee orthosis. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding any knee instability on exam. In addition, there is no documentation of any recent injury to or a surgical procedure on the knee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1851) provided on November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140)
provided on May 3, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that your dentist could not
provide the service and referred you to an endodontist. You also say that you would like this service to be
covered because you are on a limited income. The Plan denied your request. The Plan says this service exceeds
the frequency limitation 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, problem focused limited oral
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received two problem
focused limited oral evaluations (D0140 x2) on May 3, 2021, one of which was covered by the Plan, and your
problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the
Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on May 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 30, 2021,
through May 2, 2021.

You asked the Plan to pay for the self-administered drugs. You say that your arm and fingers were swollen,
painful and you couldn't move them. You say that the doctor determined to admit you to the hospital for
treatment because they could not determine the cause. The Plan denied your request. The Plan says selfadministered
drugs are not covered by the Plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from April 30, 2021, through May 2, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the request is experimental/investigational.

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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested therapy is considered experimental/investigational and has not been proven superior to surgical intervention. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment (A9270) purchased on November 17, 2020.
You asked the Plan to pay for fitness equipment. You say that you ordered the bike in 2020 and you think getting the bike in mid-December should be a benefit for 2021. The Plan denied your request. The Plan says you were already reimbursed for the 2020 Wellness Allowance Benefit in June 2020.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract for 2020 states that the Plan can pay up to $150 per calendar year toward your cost of a membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture and/or nutritional counseling. As of October 1, 2020, and until December 31, 2020, this benefit may also be used toward the purchase of exercise equipment that you can use at home. Purchases made prior to October 1, 2020, do not qualify. The Plan's rules for coverage of gym benefits have not been met because you were reimbursed for the 2020 Wellness Allowance Benefit in June 2020, therefore, your benefit for 2020 has been exhausted. Therefore, we decided that the Plan does not have to pay for fitness equipment (A9270) purchased on November 17, 2020.