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

We decided that the Plan does not have to pay for an impacted tooth removal (D7220), general anesthesia
(D9222 and D9223), and therapeutic parenteral drugs (D9612) provided by an out-of-network provider on
August 24, 2021.

You asked the Plan to pay for an impacted tooth removal, general anesthesia, and therapeutic parenteral drugs.
You say that you had no choice, and you needed the wisdom tooth removed. The Plan denied your request. The
Plan says the dental services provided were not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an
impacted tooth removal (D7220), general anesthesia (D9222 and D9223), and therapeutic parenteral drugs
(D9612) provided by an out-of-network provider on August 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction by neurolytic agent provided on August 19, 2021.

You asked the Plan to waive the copayment for the destruction by neurolytic agent. You say that you disagree with the charges because you were told that you would not owe any other copayments. 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 $45 copayment for specialist visits. 

You have been asked to pay a $45 copayment for the destruction by neurolytic agent. The destruction by neurolytic agent falls within the physician/practitioner services, including doctor's office visits 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 destruction by neurolytic agent provided on August 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110) provided on February 25, 2021.

You asked the Plan to pay for physical therapy services. You say that this is supported in thee records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that the services of a Physical Therapy Assistant (PTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. The services at issue were provided by a PTA and billed by a nurse practitioner. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scalings and root planings (D4341) provided on June 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the scalings and planings. You say that you were referred to this provider because you need a crown. You also say that no other dentist will complete what needs to be done and you would like this dentist to finish the work even though they are not in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that during your calls with the Plan you were never advised that you could go OON to receive these services.
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 periodontal scalings and root planings (D4341) provided on June 9, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the behind ear binaural hearing aid (V5140) provided February 19, 2021.

You asked the Plan to pay for the hearing aids. You say that you were told that hearing aids would be covered. The Plan denied your request. The Plan says hearing aids are only covered when provided through the Plan's hearing aid vendor.

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 provided by the Plan's hearing 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. Therefore, we decided that the Plan does not have to pay for the behind ear binaural hearing aid (V5140) provided February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like an LTACH admission covered. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to an LTACH does not meet the requirements for approval.
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 that you appear to be improving and should only require short-term additional acute care services that can be safely administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed. 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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 13, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told several times that insurance would cover your stay. The Plan denied your request. The Plan says the claims were process 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 $400 copayment for each covered hospital stay until discharge for inpatient hospital care. 

You have been asked to pay a $400 copayment for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care 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 inpatient hospital care provided on January 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the cinnamon capsules and apple cider vinegar purchased on May 18, 2021.

You asked the Plan to pay for the cinnamon capsules and apple cider vinegar. You say that you would like reconsideration because you were told these items would be reimbursed in full. The Plan denied your request. The Plan says you have exceeded the limit of your Instant Savings Card Allowance for the quarter requested.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for over-the-counter (OTC) items. The Plan offers a benefit which exceeds Medicare coverage, so the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan rules for coverage have not been met. Specifically, the record indicates that you had a balance of $24.45, which was reimbursed to you. The remaining charges exceed your benefit limit of $112 per quarter. Your benefit for the requested items has been exhausted.

Therefore, we decided that the Plan does not have to pay for the cinnamon capsules and apple cider vinegar purchased on May 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on May 3 to June
1, 2021, by an out-of-network provider.

You asked the Plan to pay for outpatient mental health services. You say that you have obtained authorization
for these services starting from June 6, 2021, but services prior to this date should be reconsidered for payment.
The Plan denied your request. The Plan says rules for payment for out-of-network services have not been met.

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 outpatient mental health services provided on May
3 to June 1, 2021, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on May 14, 2021, and June 22, 2021.

You asked the Plan to waive the copayments for ambulance services. You say that you were not aware that calling 911 was an out-of-network service. You state that you cannot afford the charges. 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 $260 copayment for ambulance services. 

You received ambulance services on May 14, 2021, and June 22, 2021. Therefore, you are responsible to pay a $260 copayment per each ambulance service. The total amount you owe is: $520.

You have been asked to pay the total copayment amount of $520 for ambulance services. Ambulance services fall within the ambulance 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 copayments for ambulance services provided on May 14, 2021, and June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0480) rendered by the out-of-network (OON) provider on July 7, 2021 and August 4, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services 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 the drug testing services (80307, G0480) rendered by the out-of-network (OON) provider on July 7, 2021 and August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) machine provided from August 31, 2021, to September 30, 2021.
You asked the Plan to waive the coinsurance for the CPAP machine. You say that you feel the device should be replaced without additional charges. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for each durable medical equipment (DME) item, including CPAP machines.
Item
Allowed Amount
20% Coinsurance
CPAP - August 31, 2021
$44.56
$8.91
CPAP - September 30, 2021
$44.56
$8.91
CPAP Humidifier - August 31, 2021
$14.26
$2.85
CPAP Filter - August 31, 2021
$6.72
$1.34
CPAP Tubing - August 31, 2021
$15.05
$3.01
CPAP Humidifier -September 30, 2021
$14.26
$2.85
Total:
$27.87
You have been asked to pay $27.87, which is 20% of the allowed amount for the CPAP machine. The CPAP machine falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a continuous positive airway pressure (CPAP) machine provided from August 31, 2021, to September 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and endodontic
therapy (D3310) provided on June 7, 2021, by an OON provider.

You asked the Plan to pay for the first intraoral periapical x-ray and endodontic therapy. You say that you
would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the treating
provider is not a participating provider with your plan. The Plan also says that you self-referred to a nonparticipating
provider for routine care.

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 first
intraoral periapical x-ray (D0220) and endodontic therapy (D3310) provided on June 7, 2021, by an OON
provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on
August 3, 2021.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that this should be
considered a preventative service and you should not owe a copayment. 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 $40
copayment for routine radiology services.

The medical records show that you received a diagnostic mammogram on August 3, 2021. Therefore, you are
responsible to pay the $40 copayment.

You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on August 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and a guided tissue regeneration, resorbable barrier, per site (D4266).

You asked the Plan to pre-approve a bone replacement graft and a guided tissue regeneration. You say that you are asking for reconsideration of the denial stating that you believe this is medically necessary. The Plan denied your request. The Plan says the requested services are not listed and therefore 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 a bone replacement graft (D4263) and a guided tissue regeneration, resorbable barrier, per site (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2330) provided on August 23, 2021.
You asked the Plan to pay for the fillings. You say that you chose a dentist who was close to you and had services done. No one informed you at any point that this provider was out-of-network or that these services would not be covered. The Plan denied your request. The Plan says the provider in question is not part of the Plan's dental network. Out-of-network dental care is 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. Services obtained from providers outside of the Plan's dental vendor network are not covered. Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network items or services are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings (D2330) provided on August 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital care and emergency care provided from June 4, 2021, to August 16, 2021.
You asked the Plan to waive the copayments for inpatient hospital care and emergency care. You say that a physician prescribed the wrong medication which almost killed you and resulted in the inpatient hospital stay and emergency 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 $225 copayment for days 1-7 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $90 copayment for emergency care. You received inpatient hospital care from June 4, 2021, to June 6, 2021. Therefore, you are responsible to pay a $225 copayment for days 1-2 (June 4, 2021, to June 5, 2021). The total amount you owe for inpatient hospital care is: $225 (copayment) x 2 (inpatient hospital care) = $450. You received emergency care on August 16, 2021. Therefore, you are responsible to pay the $90 copayment. The total amount you owe is: $540. You have been asked to pay the total copayment amount of $540 for inpatient hospital care and emergency care. Inpatient hospital care falls within the inpatient hospital care benefit category. Emergency care falls within the emergency care 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 inpatient hospital care and emergency care provided from June 4, 2021, to August 16, 2021.