Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you had on February 17, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayment for the MRI. You say that it was impossible for you to receive the MRI at your primary care physician's office. 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 $200 copayment for diagnostic radiology services performed by a provider other than your primary care provider.
You have been asked to pay a $200 copayment for the MRI. The MRI falls within the diagnostic radiology services performed by a provider other than your primary care provider benefit category. There is no provision in your contract requiring your Plan to offer all diagnostic radiology services at a primary care physician's office. 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 magnetic resonance imaging (MRI) you had on February 17, 2021, at an outpatient hospital facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral x-rays (D0220, D0230), bitewing x-rays (D0274), panoramic x-ray (D0330) and dental cleaning (D1110) provided on February 11, 2021.
You asked the Plan to pay for the dental services. You say these were simple preventative services and should be covered in full. The Plan denied your request. The Plan says that they have paid the full allowed amount for the services you received; however, the provider in question is not part of the Plan's network and billed an amount that is greater than what the Plan allows for these services. You are responsible for this difference in cost.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's rules apply in this case. Your contract with the Plan clearly says that the Plan will only pay up to a certain amount for covered dental services, and if you receive services from an out-of-network provider, you may be billed for any amount greater than what the Plan pays for services.
The provider billed the Plan a total of $635 for the evaluation, cleaning and x-rays. The Plan covers these services; however, the Plan's total combined allowed amount for this care is $269. This is the amount that a network dentist would accept as full payment for these services, but out-of-network dentists do not have this agreement with the Plan. The record shows that the provider in this case is not part of the Plan's dental network. The Plan has paid the full allowed amount for the dental care, but you are responsible for the difference between what the dentist billed and what the Plan paid ($635 - $269 = $366). 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 pay for the comprehensive oral evaluation (D0150), intraoral x-rays (D0220, D0230), bitewing x-rays (D0274), panoramic x-ray (D0330) and dental cleaning (D1110) provided on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram and breast ultrasound you had at an outpatient hospital facility on April 12, 2021.
You asked the Plan to waive the copayment for the diagnostic mammogram and breast ultrasound. You say that you intended just to get a routine mammogram. 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 $100 copayment for outpatient diagnostic tests at an outpatient hospital. You have been asked to pay a $100 copayment for the diagnostic mammogram and breast ultrasound. The diagnostic mammogram and breast ultrasound fall within the outpatient diagnostic tests at an outpatient
hospital 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 the diagnostic mammogram and breast ultrasound you had at an outpatient hospital facility on April 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit (99214) provided on June 7, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the service provided.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not provided medical records to substantiate the services provided and billed in this case. Therefore, we decided that the Plan has to waive the copayment for the office visit (99214) provided on June 7, 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 April 15, 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 April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (37224, 75710) provided November 12, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 37224, & 75710 are not supported in the medical record. Specifically, a single incision was made over the enrollee's prior fem-pop bypass at thigh level. All subsequent procedures, proximal and distal, were performed from this single incision/access site. As such, one procedure on one extremity should be billed (CPT 34201). Imaging for procedures is included in the procedure code and, therefore, not billed separately.
Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (37224, 75710) provided November 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), anti-reflective coating (V2750),
polycarbonate lenses (V2784), tint addition to lenses (V2745) and progressive lenses (V2781) provided on
April 20, 2021.
You asked the Plan to pay for eyeglass frames, anti-reflective coating and lenses. You say that you were told
the last time you were fitted for new glasses was April 19, 2019. You also say you thought April 20, 2021 was
the appropriate two-year interval. You say it was imperative for you to get new glasses as the polycarbonate
coating on your old glasses had deteriorated. The Plan denied your request. The Plan says you exhausted your
vision benefit April 23, 2019.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says that you receive a routine vision exam once per year and a $240 maximum
benefit towards the purchase of eyewear every twenty-four (24) months combined in-network and out-ofnetwork.
We looked at the file and the Plan's rules. The records show that you exhausted your maximum benefit on April
23, 2019. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, antireflective
coating and lenses have not been met. Therefore, we decided that the Plan does not have to pay for
eyeglass frames (V2020), anti-reflective coating (V2750), polycarbonate lenses (V2784), tint addition to lenses
(V2745) and progressive lenses (V2781) provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation - per site (D7953).
You asked the Plan to pre-approve bone replacement grafts. You say that you are extreme pain and need this procedure done. The Plan denied your request. The Plan says this service is not covered under 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. Therefore, we decided that the Plan does not have to pre-approve bone replacement grafts for ridge preservation - per site (D7953).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast re-implant surgery and mastopexy (19316, 19325).
You asked the Plan to pre-approve the surgery. You say that this surgery was approved last year, but not done yet due to back pain. The Plan denied your request. The Plan says that this is not covered to improve appearance.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee had cosmetic surgery for breast implantation. The record indicates that the enrollee has intracapsular rupture of both implants as well as an adjacent mass and smaller lesions towards the axillary tail. The record indicates that the implants are being removed as a medically necessary procedure. The requested procedure is reconstructive in nature. The elements of the coverage criteria are satisfied. 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve breast re-implant surgery and mastopexy (19316, 19325).
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 an eye refraction (92015) provided on April 23, 2021.
You asked the Plan to pay for an eye refraction. You say that prior to your appointment you called the provider's office and was told the provider was in-network, therefore, the service should be covered as part of the routine vision exam. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when performed by a participating provider and performed as a routine screening. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) provided on
May 4, 2021.
You asked the Plan to pay for the implant placement. You say that this service was necessary. The Plan denied
your request. The Plan says this service is not covered by 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
surgical placement of implant body (D6010) provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or
established patient (D0180) provided April 1, 2021.
You asked the Plan to pay for the comprehensive periodontal exam. You say that this service was required
prior to a medically necessary dental procedure. The Plan denied your request. The Plan says this service is not
covered under 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. Therefore, we decided that the Plan does not have to pay for the
comprehensive periodontal evaluation - new or established patient (D0180) provided April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (84520, 82040, 82043, 82247, 82310, 82374, 82435, 82565, 82570, 84075, 84132, 84295, 84450, 84460, 86001, 84403, 83880, 84155, 80050) provided on August 20, 2020.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (84520, 82040, 82043, 82247, 82310, 82374, 82435, 82565, 82570, 84075, 84132, 84295, 84450, 84460, 86001, 84403, 83880, 84155, 80050) provided on August 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for implant maintenance procedures (D6080) provided on June 21, 2021.
You asked the Plan to pay for the implant maintenance procedure. You say that this service was simple and necessary, and you feel it should be covered. The Plan denied your request. The Plan says this service is not covered by 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 implant maintenance procedures (D6080) provided on June 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper denture provided on April 5, 2021 and on
June 21, 2021.
You asked the Plan to pay for the complete upper dentures. You say that you were told the insurance company
would cover $829.26 which you paid. You say that you wouldn't have had the procedure if you knew it
wouldn't be covered. The Plan denied your request. The Plan says dentures are not covered 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. Therefore, we decided that the Plan does not have to pay for the
complete upper denture provided on April 5, 2021 and on June 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements were not met for this device.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you have obstructive sleep apnea. You underwent a sleep study in June 2021. There were no central or mixed events noted. The apnea-hypopnea index is 16.5. The record does not provide objective evidence of CPAP failure as defined by the record. A titration study from 2018 demonstrates successful CPAP trial with a small mask. The elements of the coverage rule are not satisfied. 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 hypoglossal nerve stimulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a medical eye exam (92014) provided on
May 19, 2021.

You asked the Plan to reduce the copayment for a medical eye exam. You say that this was a routine eye exam
and you just want to pay the correct copayment. The Plan denied your request. The Plan says if you receive
services that address a medical condition during the same routine eye exam visit, you pay a $40 specialist
office visit copayment.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract also says that you pay $15 for one annual routine eye exam. If you receive services
that address a medical condition during the same office visit, you pay a $40 specialist office visit copayment.

We looked at the file and the Plan's rules. This service was performed for medical vision purposes. The EOC
confirms $40 is the required copayment for this service. Based on this information, we decided that the Plan's
rules for coverage of a medical eye exam have not been met. Therefore, we decided that the Plan does not have
to reduce the copayment for a medical eye exam (92014) provided on May 19, 2021.