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

 We decided that the Plan does not have to pre-approve hearing aids, monaural, in the ear (V5050) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve hearing aids. You say that the OON hearing aids are superior quality, and you would like them covered. The Plan denied your request. The Plan says hearing aids are available in-network.  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 pays for hearing aids only when purchased from a network hearing provider.  We looked at the file and the Plan's rules. 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. 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 pre-approve hearing aids, monaural, in the ear (V5050) to be provided by an out-of-network (OON) provider.   Your complaint about the quality of the hearing aids provided by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laboratory service (80051) provided on September 24, 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 the copayment has been applied correctly to the service provided.  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 $10 per day for other Medicare-covered laboratory tests that are not Fecal Immunochemical (FIT) tests.    You have been asked to pay $7.01 for the Medicare-covered laboratory test provided. This is the Plan's allowed amount for this service which is less than the applicable copayment. 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 laboratory service (80051) provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided from October 11, 2021, to October 12, 2021.  You asked the Plan to waive the copayment for outpatient hospital observation. You say that you feel that you did not receive proper observation care. 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 $350 copayment for outpatient hospital observation.   You have been asked to pay a $350 copayment for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from October 11, 2021, to October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to authorize an office visit with a non-participating oculoplastic surgeon.   You asked the Plan to authorize an office visit with a non-participating oculoplastic surgeon. You say that it is necessary to see the out-of-network provider because the provider specializes in oculoplastic surgery. The Plan denied your request. The Plan says a group of In-Network providers was given that can service the enrollees needs for surgery.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 authorize an office visit with a non-participating oculoplastic surgeon. Our reviewer says that you do not meet the criteria for treatment with the requested out-of-network provider. Our physician reviewer found the record indicates that you suffered a fall in December 2021 that resulted in facial fractures. The record indicates that you require an oculoplastic surgery referral. The record does not indicate that the Plan is unable to provide this service. The record shows that there are in-network providers available to provide the needed services. Out-of-network treatment is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an office visit with a non-participating oculoplastic surgeon have not been met. Therefore, we decided that the Plan does not have to authorize an office visit with a non-participating oculoplastic surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 5, 2021.  You asked the Plan to pay for the dental service. You say that you were given incorrect information twice by plan representatives. You say that this led to extra expenses. You say that you were not aware that a panoramic x-ray and complete series x-ray were the same type of service. You also say that you would not have had any way of knowing this. The Plan denied your request. The Plan says 1 panoramic x-ray or complete series x-ray is covered every 5 years. The Plan also says that the frequency limit has been exceeded.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete series x-ray that you received on December 22, 2020, which shares a frequency limit with panoramic x-ray of 1 every 5 years. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 5, 2021.   Your complaint about being misled by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids provided on August 28, 2021.  You asked the Plan to pay for the hearing aids. You say that the hearing aids were the exact same offered at in-network providers for thousands of dollars more. You say that the decision to go out-of-network and recover $1,400 should be reconsidered. The Plan denied your request. The Plan says you must receive care from a network provider.  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 pays for hearing aids only when they are received from the Plan's hearing aid vendor.   We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the hearing aids were not purchased from the Plan's hearing aid vendor. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on August 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided September 10, 2021.  You asked the Plan to pay for the cone beam CT scan. You say that this procedure was a necessary service. 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 cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2750).  You asked the Plan to pre-approve the crown. You say that your tooth is broken in two places, and you are unable to get it fixed. The Plan denied your request. The Plan says this procedure is not included in the benefits section of your Evidence of Coverage.  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 a crown (D2750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for 4 simple extractions (D7140), and 1 surgical extraction (D7210) provided on October 18, 2021.  You asked the Plan to pay for the extractions. You say that 6 of your teeth were infected. You say that you went to the only dentist that could take you at the time of need. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental service received out of network are not covered.  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 4 simple extractions (D7140), and 1 surgical extraction (D7210) provided on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product (D7921) and bone replacement graft for ridge preservation (D7953), or pay more for the surgical extraction (D7210) provided on August 24, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the collection and application of autologous blood concentrate product and bone replacement graft, and to pay more for the surgical extraction. You say that the Plan sent you two referral sheets for providers that accepted your insurance. The Plan denied your request. The Plan says the collection and application of autologous blood concentrate product and bone replacement graft are not covered expenses under your dental plan. The Plan says that these services were rendered by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to this 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, collection and application of autologous blood concentrate product (D7921) and bone replacement graft for ridge preservation (D7953) are not among those covered under this benefit. The contract also says that you are responsible for a 55% coinsurance for the extraction, plus the difference between the billed amount and allowed amount because the service was received OON. Therefore, we decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product (D7921) and bone replacement graft for ridge preservation (D7953), or pay more for the surgical extraction (D7210) provided on August 24, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that this admission is medically necessary. The Plan denied your request. The Plan says the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for surgical repair of a femur fracture after a fall.  The enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs provided on June 1, 2021, and August 24, 2021.  You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree with the charges because you were never charged in the past. 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 20% coinsurance for Medicare Part B prescription drugs.   You received Medicare Part B drugs on June 1 2021. The total allowed amount is $5.74 and 20% of that is $1.15.  You received Medicare Part B drugs on August 24, 2021. The total allowed amount is $5.55 and 20% of that is $1.11.  The total amount you owe is: $2.26.  You have been asked to pay the total coinsurance amount of $2.26 for Medicare Part B prescription drugs. Medicare Part B prescription 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 coinsurance for Medicare Part B prescription drugs provided on June 1, 2021, and August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that only a stationary gaseous oxygen system (E0424) and related contents (E0441) are covered for the treatment of cluster headaches for beneficiaries enrolled in a clinical trial approved by Medicare.  We looked at the file and Medicare rules. The item at issue is a portable oxygen system for the treatment of cluster headaches. Medicare covers only stationary oxygen systems for the treatment of cluster headaches for enrollees in a Medicare-approved clinical trial. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete lower denture (D5120).  You asked the Plan to pre-approve the dental service. You say that your dentures fell out of your mouth and broke. You say that you cannot eat without your dentures. You also say that eating causes you pain to eat without dentures. The Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan also says that the frequency limit has been reached.  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 and dentures are covered, the frequency limit has been reached. The record shows that the Plan paid for a complete lower denture that you received on January 18, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve excision of benign lesion up to 1.25 cm (D7410), initial apicoectomy (D3421), additional apicoectomy (D3426), and retrograde filling (D3430).  You asked the Plan to pre-approve the dental services. You say that you do not want to lose another tooth. You say that you need these services to prevent losing another tooth. You also say that this is your last resource. The Plan denied your request. The Plan says the excision of benign lesion is not listed as a covered service. The Plan says that apicoectomies are not listed as covered. The Plan also says that retrograde filling is not listed as a covered service either.  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 excision of benign lesion, apicoectomies, and retrograde filling are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve excision of benign lesion up to 1.25 cm (D7410), initial apicoectomy (D3421), additional apicoectomy (D3426), and retrograde filling (D3430).
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of a catheter; complicated (51703), and initial hospital care (99221) provided on April 3, 2021.  You asked the Plan to pay for the outpatient services. You say that the enrollee was not enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on April 2, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the insertion of a catheter; complicated (51703), and initial hospital care (99221) provided on April 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy visit provided by an in-network provider on November 10, 2021.  You asked the Plan to waive the copayment for the physical therapy visit. You say that you had met your maximum out-of-pocket amount and you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $40 copayment for physical therapy at an in-network specialist's office or comprehensive outpatient rehabilitation facility.   You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" benefit category. The record shows a new insurance policy became effective on November 1, 2021, and you had not met your maximum out-of-pocket amount with the new policy.   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 physical therapy visit provided by an in-network provider on November 10, 2021.