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

We decided that the Plan does not have to pre-approve a cardiology office visit (99214) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that the enrollee has used this provider for years and would like to continue. The Plan denied your request. The Plan says there are in-network providers available that can provide this service.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a cardiology office visit (99214) to be provided 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 surgical extraction (D7210) to be provided by an oral surgeon.

You asked the Plan to pre-approve the extraction. You say that you were referred to an oral surgeon by multiple dentists because the tooth that needs to be extracted is the canine, which the root is too large and complicated for a regular dentist to extract. The Plan denied your request. The Plan says dental services are only covered by your plan when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon 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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laser light accessory (E1399).
You asked the Plan to pre-approve a laser light. You say that the purpose of the laser light is intended to reduce
the enrollee's risk of falls. The laser light provides a visual cue or a goal which serves to ease the initiating of
his gait. The Plan denied your request. The Plan says a laser light is a non-covered enhancement accessory.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a laser light accessory (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says screening panels/testing with no relation to a medical diagnosis of disease for the 
health of the patient are 
not a benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no specific clinical rationale for the obtained laboratory tests. The review has determined that 
the services at issue in this case were 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on March 2, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to pay for the vision services. You say that it was not explained to you that the provider needed to be an in-network vision provider for eye refraction testing to be covered. The Plan denied your request. The Plan says the provider is not an in-network vision provider and therefore the refraction is not covered by the Plan.

We decided that the Plan has to waive the coinsurance for the progressive lens, per lens (V2781) and anti-reflective coating, per lens (V2750).

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $45 for routine eye exams (limit one exam every calendar year). 

The Plan says you must pay 18% coinsurance of the total amount for services from an in-network provider for the vision services and applied $27.20 coinsurance. Based on the Plan contract however, the Plan covers up to $200 allowance every year for up to one pair of prescription eyeglasses or contact lenses. The Plan contract does not show that there is no coinsurance for eyewear. The records do not show that any of the $200 allowance had previously been used. Based on the Plan contract, you cannot be asked to pay more than the $45 copayment that was applied for the vision exam. Therefore, we decided that the Plan has to waive the coinsurance of $27.20.

We also decided that the Plan does not have to pay for the determination of refraction state (92015).

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 obtained through an in-network vision provider. 

We looked at the file and the Plan's rules. The provider is not an in-network vision provider and therefore the refraction is not covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to waive the copayment for determination of refraction state (92015).
.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had at an ear, nose, and throat surgery center on May 19, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that the provider initially told you that this test would be covered 100%. The office only asked for a $40 copayment, but later billed you for this CT scan. 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 CT scans provided by any provider other than your primary care physician.

You have been asked to pay a $200 copayment for the CT scan. 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 computed tomography (CT) scan you had at an ear, nose, and throat surgery center on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions (D7311), removal of torus mandibularis (D7473), evaluation for moderate sedation (D9219), and deep sedation/general anesthesia (D9222) provided on January 13, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the alveoloplasty, removal of torus mandibularis, evaluation for moderate sedation, and deep sedation/general anesthesia. You say that you did everything you were to do. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective May 8, 2017, to May 8, 2023.

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 by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions (D7311), removal of torus mandibularis (D7473), evaluation for moderate sedation (D9219), and deep sedation/general anesthesia (D9222) provided on January 13, 2021 by a Medicare opt out provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hand-held low vision aids.
You asked the Plan to pre-approve hand-held low vision aids. You say that you recently acquired a new pair of eyeglasses, however, you are still having troubles with you eyesight. You say acquiring a low vision device is a recommendation by your optometrist. The Plan denied your request. The Plan says your Plan does not cover this particular item- low vision device, under any condition.
The Plan must follow Medicare rules. The rules say that Medicare does not cover low vision aids.
We looked at the file and the Plan's rules and the Medicare rules. The Plan and Medicare say that low vision aids are not covered. Therefore, we decided that the Plan does not have to pre-approve hand-held low vision aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the total billed amount for eyewear provided on 
May 24, 2021. 
 
You asked the Plan to reimburse you the total billed amount for the eyewear. The Plan denied your request. 
The Plan says your benefit only covers up to the maximum allowed amount of the $150 eyewear allowance. 
 
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum allowed amount 
of $150 for the eyewear allowance benefit. Therefore, we decided that the Plan does not have to reimburse you 
the total billed amount for eyewear provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmological examination to be provided by the requested out-of-network provider at the in-network benefit level.

You asked the Plan to pre-approve ophthalmological examination to be provided by the requested out-of-network provider at the in-network benefit level. You say that you are spending the winter months in Arizona, and the nearest in-network provider is more than 550 miles away in Utah. You say that traveling that far for services is unacceptable, as is waiting until spring to address your medical condition. You say that because you live on a very restrictive fixed income, paying the out-of-network rate is financially impossible. The Plan denied your request. The Plan says as a member of our plan, you can choose to receive care from out of network providers. Our Plan will coverage services from either in-network or out-of-network providers as long as the services are covered benefits and medically necessary. However, if you use an out of network provider, you share of the costs for your covered services may be higher.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan will coverage services from either in-network or out-of-network providers as long as the services are covered benefits and medically necessary. However, if you use an out of network provider, you share of the costs for your covered services may be higher.

The requested provider in this case is not a network provider with the Plan. The Plan covers services from either in-network or out-of-network providers as long as the services are covered benefits and medically necessary. However, if you use an out of network provider, you share of the costs for your covered services may be higher. We found no exception that would require the Plan to pre-approve these services at the in-network benefit level. Therefore, we decided that the Plan does not have to pre-approve ophthalmological examination to be provided by the requested out-of-network provider at the in-network benefit level.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placements (D6010) and implant
supported denture (D6110).

You asked the Plan to pre-approve the surgical implant placements (D6010) and implant supported denture
(D6110). You say that her dry mouth has resulted in significant tooth decay which is affecting her overall
health. You say that it is medically necessary for her to be approved for the extractions and implants. The Plan
denied your request. The Plan says the services 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 pre-approve the
surgical implant placements (D6010) and implant supported denture (D6110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair broken complete denture base, mandibular, (D5511) provided on June 10, 2021.

You asked the Plan to pay for the dental service. You say that you had a bottom denture that had broken once before. You say that it broke again. You say that your dentist advised that the denture was made too thin and that it would break again. You also say that this is not your fault. The Plan denied your request. The Plan says repair broken complete denture base, mandibular, is limited to once per plan year.

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 services is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a repair broken complete denture base, mandibular, that you received on January 11, 2021. Therefore, we decided that the Plan does not have to pay for the repair broken complete denture base, mandibular, (D5511) provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve wound care to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate that the requested shoe inserts are an integral part of a covered leg brace.

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. 

Records show that you do not suffer from diabetic foot disease and you do not 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 foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Injectafer and saline infusions you received from May 5, 2021, to May 12, 2021.

You asked the Plan to waive the coinsurance for the Injectafer and saline. You say that when you got this plan, you thought there was no cost sharing. 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 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay 20% coinsurance for the Injectafer and saline. The Injectafer and saline fall within the Medicare Part B 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 the Injectafer and saline infusions you received from May 5, 2021, to May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions, inhalation of nitrous oxide and drugs or medicaments provided on April 9, 2021.
You asked the Plan to pay for the extractions, inhalation of nitrous oxide and drugs or medicaments. You say that you were told you would have a copayment and you were not told the claim had to be pre-certified. The Plan denied your request. The Plan says the services are not covered benefits.
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. Therefore, we decided that the Plan does not have to pay for the extractions, inhalation of nitrous oxide and drugs or medicaments provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6010).

You asked the Plan to pre-approve the services. You say that standard procedures are not an option. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pre-approve 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. Therefore, we decided that the Plan does not have to pre-approve dental services (D6010).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after September 
19, 2021. 
 
You asked the Plan to pre-approve SNF care. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says that medical necessity cannot be established for 
continued SNF level of coverage. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before September 19, 2021.  The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after September 19, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on May 20, 2021. 
 
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says per the Plan benefits, 
the hearing aid benefit items are only to be supplied by the Plan's hearing aid provider and since this was not 
done this is not a covered benefit. 
 
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 provided by the Plan's hearing aid provider. 
 
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's 
hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids 
have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on  
May 20, 2021.