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

We decided that the Plan does not have to pay for the oral evaluation (D0120), bitewing x-ray (D0274), panoramic x-ray (D0330), prophylaxis (D1110), and the application of fluoride varnish (D1206) provided on March 23, 2021.

You asked the Plan to pay for the dental services. You say that you though they accepted your insurance at the time. You also say that you would appreciate some payment. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.

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 oral evaluation (D0120), bitewing x-ray (D0274), panoramic x-ray (D0330), prophylaxis (D1110), and the application of fluoride varnish (D1206) provided on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve injections. You say that you would like the Plan to approve these injections. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 injections to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a pain management specialist you had on April 6, 2021.

You asked the Plan to waive the copayment for the pain management visit. You say that you cannot afford this cost sharing. 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 $25 copayment for visits with a specialist.

You have been asked to pay a $25 copayment for the pain management visit. The pain management visit falls within the visits with a specialist 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 office visit with a pain management specialist you had on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic shoes.

You asked the Plan to pre-approve the requested items. You say that you have abnormalities in each toe. The
Plan denied your request. The Plan says orthopedic footwear is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

We looked at the file and the rules. The records do not show that you suffer from diabetic foot disease or that
you wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides
coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve
orthopedic shoes.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 15, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER for syncope and vomiting and went through triage. You said that after six hours you were not seen by a doctor, so you left. 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 $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER visit. This copayment applies each time you visit the ER, regardless of the extent of services you receive. 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 emergency room (ER) visit you had on March 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of Reblozyl (J0896).

You asked the Plan to pre-approve the continuation of Reblozyl. The Plan denied your request. The Plan says this request does not meet the medical necessity criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 continuation of Reblozyl. Our reviewer says that Reblozyl (J0896) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the records do not document a decrease in transfusion burden since starting the treatments in May 2020 and is not safe and effective for the enrollee. 

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 continuation of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of Reblozyl (J0896).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided by on May 28, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that this is your second visit for top dentures and the first visit should not have been paid. You say that you should not have to pay $116 for a visit that should have waited. The Plan denied your request. The Plan says reimbursement for a comprehensive oral evaluation has already been issued.
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, you also have a maximum benefit of one comprehensive oral evaluation every three years. The Plan paid for the comprehensive oral evaluation provided on May 3, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation provided by on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212).

You asked the Plan to pre-approve the mandibular partial denture. You say that you need this denture because
it is necessary. The Plan denied your request. The Plan says this service is limited to once per 60 months. The
Plan also says that you received a complete mandible denture less than 60 months ago.

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, mandibular partial denture (D5212) is
limited to one of either codes D5120, D5140, D5212, or D5214 once per 60 months. The record shows that you
received a complete mandibular denture (D5120) on March 8, 2018 and your mandibular denture benefit has
been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture
(D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950), retainer crowns (D6750 x 2), and pontic (D6240) provided on April 26, 2021.
You asked the Plan to pay for the dental services. You say that you feel that the services you received were not for cosmetic reasons. You say that you needed these services so that you would be able to eat and maintain your dental health. You also say that you were reassured that this cost would be covered under your plan. The Plan denied your request. The Plan says the core build up is not listed as a covered service. The Plan says that the retainer crowns and pontic are not listed as covered services either. The Plan also says there is no record that you contacted the plan to verify benefits prior to the date of 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 core build up, retainer crowns, and pontic are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950), retainer crowns (D6750 x 2), and pontic (D6240) provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam you had on April 5, 2021.

You asked the Plan to waive the copayment for the eye exam. You say that this was a routine exam so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly because this was a medical eye exam.

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 medical eye exams. 

You have been asked to pay a $40 copayment for the eye exam. The records show that in addition to any routine care, you were also evaluated for an age-related cataract. This is a medical condition, so the eye exam falls within the medical eye exams 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 eye exam you had on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) prothrombin time (85610) provided on January 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 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 hospital outpatient clinic visit (G0463) prothrombin time (85610) provided on January 5, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 19, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for tomographic myocardial perfusion imaging (78452) provided on October 7, 2020.

You asked the Plan to waive the copayment for tomographic myocardial perfusion imaging. You say that the copayment is too high and that you already paid a copayment when you went for the visit. The Plan denied your request. The Plan says the correct copayment was 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 $175 copayment for each Medicare-covered advanced radiology service. Your contract also says that, if advanced radiology services are performed in the provider's office during an office visit, the appropriate office visit copayment and advanced radiology service copayment will apply. 

You have been asked to pay a $175 copayment for tomographic myocardial perfusion imaging. Tomographic myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for tomographic myocardial perfusion imaging (78452) provided on October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve the Euflexxa. The Plan denied your request. The Plan says the information
submitted does not meet the Plan's medical necessity guidelines for coverage.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Euflexxa. Our reviewer says that
Euflexxa is not approved as step criteria is not met. Our physician reviewer found the enrollee has not trialed
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires
these be trialed first. Our reviewer also found that the documentation does not outline contraindications or
reasons these medications were not considered.

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 Euflexxa have not been met. Therefore, we decided that the Plan does not
have to pre-approve Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cortisone injection provided at an
outpatient hospital on October 2, 2020.
You asked the Plan to waive the copayment for a cortisone injection. You say that, because the service at issue
was due to an accident, you believe the copayment is not correct. The Plan denied your request. The Plan says
the correct copayment was 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 $175
copayment for surgery services at an outpatient hospital.
You have been asked to pay a $175 copayment for a cortisone injection. A cortisone injection falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" 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 a cortisone injection
provided at an outpatient hospital on October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the inpatient hospital admission and services provided from February 28, 2021, to March 4, 2021.
You asked the Plan to waive the cost-share for the inpatient care. You say that you are on a fixed income and cannot afford these charges. The Plan denied your request. The Plan says the claim was processed correctly, and your cost-share was assessed in accordance with your contract.
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 says that there is a $1,000 deductible which applies to inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $795 copayment per inpatient hospital stay after you meet your $1,000 deductible. You have been asked to pay $1,068.72 for the inpatient care. Documentation shows that prior to these services, you had not contributed any amount to your annual deductible. 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 cost-share for the inpatient hospital admission and services provided from February 28, 2021, to March 4, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve denture repair services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON denture repair services. You say that you cannot eat and are missing teeth on the bottom row. You say that you have been only eat soft foods as of lately. You say that the requested provider is who originally made your implants a few years ago. The Plan denied your request. The Plan says there is no gap issue and there are in network providers available who can supply the requested services.
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 denture repair services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services
provided from January 4, 2021, through January 28, 2021, and the rehabilitation therapy and diagnostic lab
services provided from February 5, 2021, through February 17, 2021.
You asked the Plan to waive the copayment for the SNF services, the rehabilitation therapy and diagnostic lab
services. You say that you were not aware the enrollee would be responsible for these charges. The Plan denied
your request. The Plan says the copayments were applied 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 $160 copayment per day for days 21-100 of SNF care, a $35 copayment for each rehabilitation
therapy service received in a hospital or SNF and a $10 copayment for each basic imaging service received in a
hospital or SNF.
The enrollee has been asked to pay a $950 copayment for the SNF services, the rehabilitation therapy services
and diagnostic lab services. The SNF services fall within the per day for days 21-100 of SNF care, the
rehabilitation therapy services fall within the rehabilitation therapy service received in a hospital or SNF and
the diagnostic lab services fall within the basic imaging service received in a hospital or SNF benefit category.
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 the skilled nursing facility (SNF) services
provided from January 4, 2021, through January 28, 2021, and the rehabilitation therapy and diagnostic lab
services provided from February 5, 2021, through February 17, 2021.