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

 We decided that the Plan does not have to pay for the periodic oral evaluation and periodontal maintenance 
provided on July 7, 2021. 
 
You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that you have 
a documented history of periodontal disease and the procedures were covered in the past. You say that they are 
clearly covered in the handbook and the decision should be reversed. The Plan denied your request. The Plan 
says dental services are only covered if you are enrolled in the supplemental Dental Platinum Rider. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. You can contact the Plan regarding enrolling in the optional supplemental dental benefits. 
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and periodontal 
maintenance provided on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the heart monitor replacement surgery 
(33249, 33233), provided on April 26, 2021. 
 
You asked the Plan to waive the copayment for the heart monitor replacement surgery. You say that you 
disagree with the cost share. The Plan denied your request. The Plan says the cost share was 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). Your contract with the Plan clearly says that you must pay a $450 
surgery services copayment for outpatient hospital services.  
 
You have been asked to pay a $450 surgery services copayment for the heart monitor replacement surgery. 
This service falls within the outpatient hospital services 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 heart monitor replacement surgery (33249, 33233), provided on April 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine, provided on April 6, 2021. 
 
You asked the Plan to pay for the shingles vaccine. You say that this service should be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine, provided on April 6, 
2021.  
 
Benefits for the shingles vaccine 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the replace missing or broken teeth - complete denture (each
tooth) (D5520) provided July 15, 2021.

You asked the Plan to pay for replacement of broken tooth on denture. You say that you did not know your
tooth would break and you were in pain. 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
replace missing or broken teeth - complete denture (each tooth) (D5520) provided July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the present setting where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided June 14, 2021.

You asked the Plan to pay for the limited oral exam. You say that you were in pain and needed another consultation. The Plan denied your request. The Plan says you have exceeded the frequency limit 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. The Plan covers the limited oral exam once per plan year. 

We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on May 26, 2021.

Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided June 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound you had on June 
15, 2021. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you were told that the 
copayment was $0.  You said that had you known about the copayment, you wouldn't have had this test. The 
Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that 
because the allowed amount for this service ($126.66) is less than your copayment obligation, you are 
responsible for the full allowed amount. 
 
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 $160 
copayment for radiological diagnostic services.  
 
You have been asked to pay a $160 copayment for the abdominal ultrasound. The abdominal ultrasound falls 
within the radiological diagnostic services 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 abdominal ultrasound you had on June 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on June 
25, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you don't think you 
should have to pay this copayment because the hospital did not help you. 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 $150 
copayment per trip for ambulance services.  
 
You have been asked to pay a $150 copayment per trip for the ambulance services. This copayment applies 
regardless of the reason for the transport. 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 ambulance 
services you received on June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the doctor has confirmed that the enrollee is not currently on insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 or 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on June 4, 2021.

You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 services at issue in this appeal. 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 an office visit (99213) provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive your coinsurance for services you had at an out-of-network clinic on June 28, 2021.

You asked the Plan to waive your coinsurance for the out-of-network clinic services. You say that you decided to find a doctor who took your insurance why on vacation. This provider was great and got you back on track. You said that you need to go to a doctor regularly and you think the cost is too high. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network provider and professional services. 

You have been asked to pay 50% coinsurance for the out-of-network clinic services. The out-of-network clinic services falls within the out-of-network provider and professional services 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 your coinsurance for services you had at an out-of-network clinic on June 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 20, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 20, 2021, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 20, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of November 20, 2021, forward. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment beyond November 20, 2021, as he was not 
a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve the enrollee?s condition or for 
the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 20, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 20, 
2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The 
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at 
the LTACH that are not available at the present setting where she is currently receiving care. There are no 
services available at the LTACH that the enrollee requires that are not available at the health care setting being 
offered by the health plan. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a commode chair (E0165), and walker (E0141), provided on
May 5, 2021.

You asked the Plan to pay for a commode and walker. You say that the items were medically necessary. The
Plan denied your request. The Plan says all claims for items billed to Medicare require a written
order/prescription from the treating practitioner as a condition for payment.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid physician order. You purchased the items without a prescription from your
physician. Therefore, we decided that the Plan does not have to pay for a commode chair (E0165), and walker
(E0141), provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on July 26, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not aware 
that the provider was OON at the time of service because the office confirmed they accepted your insurance. 
The Plan denied your request. The Plan says these services were rendered by an OON provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on July 26, 2021 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removable occlusal guard (D9944).
You asked the Plan to pre-approve the occlusal guard. You say that this item is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation to verify if this may be a covered item/service or if it is medically necessary.
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. In this case, and removable occlusal guard was requested for this enrollee. Dental x-rays were submitted, but there was no narrative provided for review. Without this information, it cannot be determined whether or not the item at issue is requested for a purpose that may be covered by Medicare. With the information provided, we must assume that the requested service is dental in nature and would be covered under the enrollee's dental benefit. However, while 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 a removable occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for eye injections and does not have to waive 
the coinsurance for Medicare Part B drugs provided on July 20, 2020, to March 4, 2021. 
 
You asked the Plan to waive the copayments for eye injections and to waive the coinsurance for Medicare Part 
B drugs. You say that you would like the billing discrepancies to be sorted out. The Plan denied your request. 
The Plan says the claims were processed correctly, and you are being charged the correct amount. 
 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 $500 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare 
part B prescription drugs.  
 
The record shows that you received eye injections and Medicare Part B drugs at an outpatient hospital facility 
from July 20, 2020, to March 4, 2021. Therefore, you are responsible to pay your share of the costs-sharing 
charges. Please see the chart below.  
 
Date of Service Service Allowed Amount Amount You Owe 
7/20/2020 Medicare Part B Drug $7.27 $1.45 
10/29/2020 Eye Injection $304.97 $304.97 
10/29/2020 Medicare Part B Drug $1,362.49 $272.50 
8/20/2020 Eye Injection $304.97 $304.97 
8/20/2020 Medicare Part B Drug $1,362.49 $272.50 
12/21/2020 Eye Injection $304.97 $50 
12/21/2020 Medicare Part B Drug $1,357.33 $271.47 
3/4/2021 Eye Injection $310.38 $50 
3/4/2021 Medicare Part B Drug $6.87 $1.37 
 
The total amount you owe is: $1,529.23. 
 
You have been asked to pay the total amount of $1,529.23 for eye injections and Medicare Part B drugs. Eye 
injections fall within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. Medicare Part B drugs fall within the Medicare part B 
prescription drugs 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 copayments for eye injections and 
does not have to waive the coinsurance for Medicare Part B drugs provided on July 20, 2020, to March 4, 2021.