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

We decided that the Plan does not have to waive the copayment for a diagnostic eye exam provided on June 18, 2021.
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that you received a routine eye exam and should not be responsible for 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 $40 copayment for diagnostic eye exams and a $0 copayment for routine vision services. The medical records show that you received a diagnostic eye exam on June 18, 2021. Therefore, you are
responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a diagnostic eye exam. A diagnostic eye exam falls within the vision 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 a diagnostic eye exam provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for comprehensive oral evaluation (D0150),
prophylaxis (D1110), and complete series x-ray (D0210) provided on June 29, 2021.
You asked the Plan to reimburse you for the dental services. You say that you did not know that the provider
was out of network. You also say that you would like the services to be covered. The Plan denied your request.
The Plan says the provider in this case is out of network. The Plan also says that care rendered by a provider
that is not part of our supplemental dental network 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.
Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered,
care rendered by a provider that is not part of our supplemental dental network is not covered. Therefore, we
decided that the Plan does not have to reimburse you for comprehensive oral evaluation (D0150), prophylaxis
(D1110), and complete series x-ray (D0210) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057) and implant
supported crown (D6065).
You asked the Plan to pre-approve the custom fabricated abutment (D6057) and implant supported crown
(D6065). You say that you have to get this tooth out before it gets worse and would like something put in its
place. You say that if the tooth doesn't come out it could cause a bigger problem, and this should be
reconsidered. 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
custom fabricated abutment (D6057) and implant supported crown (D6065).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from June 28, 2017, through August 2, 2017.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the claim was submitted to the Plan more than one year from date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the inpatient admission was not filed until April 26, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from June 28, 2017, through August 2, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and ophthalmic imaging provided by an out-of-network provider on August 24, 2021.
You asked the Plan to pay for the office visit and ophthalmic imaging. You say that both the facility and doctor are contracted with the Plan. You say that the claim should be reviewed per the contract. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 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 the office visit and ophthalmic imaging provided by an out-of-network provider on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on June 24, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on June 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rituximab injection provided on July 12, 2021.
You asked the Plan to waive the coinsurance for the rituximab injection. You say that you have never had to pay for your infusions and wonder if this is a mistake. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% for each Medicare-covered Part B drug.
You have been asked to pay $1,303.48, which is 20% of the allowed amount for the rituximab injection. The allowed amount is $6517.40 (20% x $6517.40 = $1,303.48). The rituximab injection falls 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 the rituximab injection provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for wound debridement services you received at an outpatient hospital facility (16020) rendered on January 10, 2021.
You asked the Plan to reduce the copayment for wound debridement services you received at an outpatient hospital facility. You say that that these visits were supposed to be office visits with just a $25 copayment. You said that you had a burn that did not require surgery. You stated that you were never advised that this would be considered an outpatient procedure and if you had known, you would not have gone as often The Plan denied your request. The Plan says you were charged 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 $250 copayment for each visit to a hospital outpatient surgical department. You have been asked to pay a $250 copayment for the wound debridement services. Wound debridement is
considered a surgical service. In addition, these services occurred in an outpatient hospital facility. That is why the wound debridement services fall within the outpatient surgery in 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 reduce the copayment for wound debridement services you received at an outpatient hospital facility (16020) rendered on January 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic care to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the chiropractic care. You say that you have been experiencing back pain, and this is medically necessary. The Plan denied your request. The Plan says the provider is out-of-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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the chiropractic care 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 pay for the limited oral evaluation (D0140), and take-home drugs (D9630) provided on June 15, 2021.
You asked the Plan to pay for the limited oral evaluation and take-home drugs. You say that you had a tooth pulled. You also say that it was supposed to be covered at 100%. The Plan denied your request. The Plan says the limited oral evaluation and take-home drugs are not listed as covered 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 limited oral evaluation and take-home drugs are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and take-home drugs (D9630) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two or more administrations of therapeutic parenteral
drugs (D9612) to be provided with a dental procedure.
You asked the Plan to pre-approve therapeutic parenteral drugs. You say that this service is necessary to bring
you out of sedation. Since the sedation was approved, you feel this service should be as well. The Plan denied
your request. The Plan says this service is not covered by your dental benefit.
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 two
or more administrations of therapeutic parenteral drugs (D9612) to be provided with a dental procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on June 25, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 80053, 80061, 83036, 85025) and the one way travel allowance in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network (OON) provider on July 14, 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 laboratory services (36415, 80053, 80061, 83036, 85025) and the one way travel allowance in connection with medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network (OON) provider on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingivectomy or gingivoplasty (D4212), gingival irrigation (D4921) and bone replacement graft (D7953).
You asked the Plan to pre-approve the gingivectomy or gingivoplasty (D4212), gingival irrigation (D4921) and bone replacement graft (D7953). 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 gingivectomy or gingivoplasty (D4212), gingival irrigation (D4921) and bone replacement graft (D7953).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physical and occupational therapy provided from
February 1, 2019, through February 16, 2019.
You asked the Plan to pay for physical and occupational therapy. The Plan denied your request. The Plan says
it is your responsibility to be sure that prior authorization is obtained, and the services are approved by the Plan
to be eligible for coverage at in-network rates. Generally, this will only occur when the care needed cannot be
obtained through in-network providers.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for physical and occupational therapy provided from February 1, 2019, through February 16, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140).
You asked the Plan to pre-approve the dental service. You say that this service should be covered. The Plan
denied your request. The Plan says 1 limited oral evaluation is covered per plan year. 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 limited oral evaluation is listed as
covered, the frequency limit has been reached. The record shows that the Plan paid for a limited oral evaluation
that you received on March 31, 2021. Therefore, we decided that the Plan does not have to pre-approve a
limited oral evaluation (D0140)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hernia surgery provided on July 23, 2021.
You asked the Plan to waive the copayment for the hernia surgery. You say that you are being charged too much for your surgery. 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 $200 copayment for each outpatient surgery and/or services at an ambulatory center or outpatient hospital facility. You have been asked to pay a $200 copayment for the hernia surgery. The hernia surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 hernia surgery provided on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable cardiac loop recorder.
You asked the Plan to pre-approve an implantable cardiac loop recorder. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria have not been met.
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 an implantable cardiac loop recorder.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the record provided does not establish the medical necessity and
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria
are not satisfied. The requested service is not recommended.
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 implantable cardiac loop recorder have not been met. Therefore, we decided
that the Plan does not have to pre-approve an implantable cardiac loop recorder.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayment for a hearing exam provided on June 2, 2021.  You asked the Plan to waive the copayment for the hearing exam. You say that you were expecting to be covered with a $0 copayment per the Plan's promotion material stating one routine hearing exam per year was covered. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.  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 a $0 copayment for one routine hearing exam per year.   The Plan says you must pay a $40 copayment for the hearing exam. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the hearing exam. There is no evidence showing that the exam was for the diagnosis or treatment of a hearing or balance issue. Therefore, we decided that the Plan has to waive the copayment for a hearing exam provided on June 2, 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.