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

 We decided that the Plan does not have to pay for the bitewing x-ray (D0274) and oral hygiene instructions (D1330) provided on August 19, 2021.  You asked the Plan to pay for the bitewing x-ray (D0274) and oral hygiene instructions (D1330). You say that the dental office took the insurance for processing and you were never informed of any discrepancy or denial. You say that it will be difficult to pay for these services. The Plan denied your request. The Plan says the services 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, you also have a maximum benefit of two x-rays per calendar year. The Plan paid for two intraoral x-rays (D0220 and D0230) provided on August 19, 2020, which exhausted your benefit. The oral hygiene instructions remain denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0274) and oral hygiene instructions (D1330) provided on August 19, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pre-approve proton beam therapy.  You asked the Plan to pre-approve proton beam therapy. You say that proton therapy is potentially more cost effective and medically necessary for breast cancer patients. You say that protons are not experimental and would minimize the dose to the heart. The Plan denied your request. The Plan says that the current medical literature indicates that the standard of care for radiation therapy of breast cancer is standard radiation therapy, including intensity modulated radiation therapy (IMRT.) The Plan says that the requested treatment is not considered medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says that proton beam therapy is considered medically reasonable and necessary in this case. Our physician reviewer found the heart exposure is minimal with both plans (as would be expected with a right sided target volume); whereas the lung V20 and lung V5 constraints are exceeded by the IMRT plan, and within acceptable limits with the proton plan. Our physician reviewer found that it is unclear whether better IMRT beam arrangements or better IMRT optimization could result in a better IMRT Plan. However, with the treatment of comprehensive nodal regions, it is plausible that the proton plan would reduce lung exposure in a meaningful manner. Therefore, proton therapy would be within accepted standards of care and its need is justified by the provided records.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have been met. Therefore, we decided that the Plan has to pre-approve proton beam therapy.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD) procedure (0275T).  You asked the Plan to pre-approve a PILD procedure. You say that the requested procedure is a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that PILD for LSS may only be covered under the context of a clinical trial.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PILD procedure have not been met. Specifically, the case record does not indicate that the enrollee is participating in an approved clinical study. Therefore, we decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD) procedure (0275T).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on June 24, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you do not think you should have to pay this copayment because you did not call the ambulance. 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 $350 copayment per trip for ambulance services.     You have been asked to pay a $350 copayment per trip for the ambulance services. This copayment applies regardless of who called for the ambulance. 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 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve services with an out-of-network provider.  You asked the Plan to pre-approve the services. You say that you have already seen an in-network provider. The Plan denied your request. The Plan says the services are available in-network.  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 services with an out-of-network 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 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  Your care needs can be met at a lower level of care.  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 pre-approve vertebral axial decompression (S9090) and low-level laser treatment (S8948).  You asked the Plan to pre-approve vertebral axial decompression and low-level laser treatment. You say that this treatment has helped you, but you cannot afford to continue paying for it. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that there is insufficient scientific data to support the benefits of vertebral axial decompression. Therefore, it is not covered by Medicare. The rules also say that low level/cold laser light therapy is considered not reasonable and necessary and is not payable by Medicare.   We looked at the file and Medicare rules. The requested services are excluded from Medicare coverage. Based on this information, we decided that Medicare rules for coverage of vertebral axial decompression and low-level laser treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve vertebral axial decompression (S9090) and low-level laser treatment (S8948).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OsteoFlo Allograft for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the OsteoFlo Allograft in the setting of anterior cervical spine fusion surgery has not been demonstrated in the peer-reviewed literature.  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 pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Osteoflow allograft remains experimental in spine surgery. More research is needed to show safety and efficacy of Osteoflow allograft use in spinal surgery. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve OsteoFlo Allograft for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the skin debridement procedures provided at an outpatient hospital facility from April 26, 2021, to May 17, 2021.  You asked the Plan to waive the copayments for the skin debridement procedures. You say that this should not be considered surgery and your specialist copayment should cover this. The Plan denied your request. The Plan says you were charged these copayments correctly.  The Plan says that because the allowed amounts for the debridement services are less than your copayment obligation, you are responsible for the full allowed amount for each service.  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 $250 copayment per visit for outpatient surgery or services at an outpatient hospital facility.   You have been asked to pay a $250 copayment per visit for the skin debridement procedures. Because these services occurred in an outpatient hospital facility, the skin debridement procedures fall within the outpatient surgery or services at an outpatient hospital facility 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 the skin debridement procedures provided at an outpatient hospital facility from April 26, 2021, to May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing images (D0274), panoramic radiographic images (D0330), full mouth debridement (D4355) intraoral images (D0220) and comprehensive oral evaluation (D0150) provided on June 2, 2021, through June 30, 2021.  You asked the Plan to pay for the dental services. You say that you would like reconsideration because you were told by the provider that they were in-network with your Plan. The Plan denied your request. The Plan says the provider was reimbursed at the Medicare Allowed Contract amount and can bill you the difference between what was billed and what was paid.  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.  We looked at your request, the file and the rules. Based on this information we have determined that criteria for additional coverage have not been met. Specifically, the record indicates that you received the dental services from an out-of-network provider. The record also shows that the Plan reimbursed the provider the Medicare Allowed Amount for these services and applied a $0 cost sharing amount. Per your contract with the Plan, the provider may bill you the difference between what was billed and what was paid. Therefore, we decided that the Plan does not have to pay for the bitewing images (D0274), panoramic radiographic images (D0330), full mouth debridement (D4355) intraoral images (D0220) and comprehensive oral evaluation (D0150) provided on June 2, 2021, through June 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond October 31, 2021.  You asked the Plan to pre-approve the continued SNF care. You say that it is felt that ongoing care is medically necessary. The Plan denied your request. The Plan says the enrollee was correctly discharged as he no longer needed daily skilled services.  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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF with diagnoses of anemia, alcohol abuse, and atrial fibrillation. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. His lungs were clear. Regarding rehabilitation services, the beneficiary received physical and occupational therapy. By the dates in question, the beneficiary was at a contact guard to minimal assist level with functional mobility including gait to 85 feet with a rolling walker.   There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care beyond October 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120).  You asked the Plan to pre-approve fixed partial denture sectioning. You say that you need this 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 pre-approve fixed partial denture sectioning (D9120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for radiation therapy services you received at an outpatient hospital facility from June 1, 2021, to June 17, 2021.  You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you were never advised of these costs prior to receiving services. The Plan denied your request. The Plan says you were charged this cost sharing 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 radiation therapy at an outpatient hospital.   You have been asked to pay 20% coinsurance for the radiation therapy services. This cost sharing is clearly disclosed in the Evidence of Coverage that every plan member is sent annually. 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 radiation therapy services you received at an outpatient hospital facility from June 1, 2021, to June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0272) and cleaning (D1110) provided on July 22, 2021, and the resin-based fillings (D2330, D2391, D2392) provided on July 28, 2021, by an out-of-network provider.  You asked the Plan to pay for the dental care. You say that you did not know this provider was out-of-network. The Plan denied your request. The Plan says these services were received out-of-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. The Plan does not cover supplemental dental care that is received from an out-of-network provider.   Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received out-of-network are not covered under this benefit. Documentation shows that the provider in question is not part of the Plan's network. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0272) and cleaning (D1110) provided on July 22, 2021, and the resin-based fillings (D2330, D2391, D2392) provided on July 28, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an MRI provided on July 13, 2021.  You asked the Plan to waive the copayment for an MRI. You say that you disagree with the high copayment 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 $300 copayment for diagnostic radiology services.   You have been asked to pay the allowed amount of $267.04, which is less than the $300 copayment for an MRI. An MRI 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 an MRI provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 9, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the visit should not warrant 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 $30 copayment for specialist services.   You have been asked to pay a $30 copayment for a specialist visit. A specialist visit 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 a specialist visit provided on June 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on March 29, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee was not treated by an eligible provider and did not have prior authorization.  Medicare rules say that plans can require enrollees to get prior authorization. The Plan contract says that for outpatient mental healthcare, providers may need to obtain prior authorization. The Plan did not pre-approve the service at issue. Therefore, we decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on March 29, 2021.