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

We decided that the Plan does not have to pre-approve a complete upper denture (D5110), a complete lower
denture (D5120), non-intravenous conscious sedation (D9248), and vesibuloplasty (D7350).
You asked the Plan to pre-approve the dental services. You say that when you had your teeth extracted, your
jaw bones were crushed. You say that you the plan should have to cover the tissue graft. You also say that your
current dentures do not fit properly. The Plan denied your request. The Plan says dentures are covered once
every 5 plan years. The Plan says that the frequency limit has been reached. The Plan also says non-intravenous
conscious sedation and vesibuloplasty 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 and dentures are listed as covered, the
frequency limit has been reached. The record shows that the Plan paid for complete dentures that you received
on October 27, 2020. Additionally, the requested says non-intravenous conscious sedation and vesibuloplasty
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to preapprove
a complete upper denture (D5110), a complete lower denture (D5120), non-intravenous conscious
sedation (D9248), and vesibuloplasty (D7350).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on August 10, 2021.
You asked the Plan to waive the coinsurance for the Part B drug. You say that you were not aware there was an extra charge for the injection. You say you were told Medicare would pay the bill. 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 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs (including certain drugs that are used with nebulizers, insulin pumps, and intravenous infusion pumps). You have been asked to pay 40.49 which is 20% of the allowed amount for the Part B drug. The allowed amount is $202.47. ($202.47 x 20% = $40.49). The Part B drug 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 Part B drug provided on August 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the resin-based composite - one surface, anterior (D2330) and resin-based composite - one surface, posterior (D2391), intraoral - periapical each additional radiographic image (D0230) and unspecified preventative procedure, by report (D1999) provided June 2, 2021, and July 21, 2021.  You asked the Plan to pay for the resin-based composites, intraoral x-rays and unspecified preventative procedures. You say that your dentist told you the services would be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for the resin-based composites and intraoral x-rays. Additionally, the Plan says that unspecified preventive procedures are not a covered 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. The Plan covers the resin-based composites twice per calendar year and intraoral x-rays once per calendar year.  We looked at the file and Medicare rules. In this case the Plan has provided documentation showing that two resin-based composites were covered on June 2, 2021, and one intraoral x-ray was covered on May 19, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the resin-based composites and intraoral x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the unspecified preventative procedure is not among those covered services. Therefore, we decided that the Plan does not have to pay for the resin-based composite - one surface, anterior (D2330) and resin-based composite - one surface, posterior (D2391), intraoral - periapical each additional radiographic image (D0230) and unspecified preventative procedure, by report (D1999) provided June 2, 2021, and July 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for physical therapy services (codes 97163, 97535) provided on June 28, 2021.  You asked the Plan to reduce the copayment for the physical therapy. You say that the bill for the physical therapy exam was correct, but the bill for "Self-Care Training" should be removed. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each physical therapy visit.   You have been asked to pay a $40 copayment for the physical therapy visit. The record shows you were charged $26.65 for self-care training. The record also shows you were charged $13.35 for a physical therapy exam, for a total of $40.00 for the visit. Physical therapy falls within the Outpatient Rehabilitation 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 reduce the copayment for physical therapy services (codes 97163, 97535) provided on June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 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 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 laboratory services (36415, 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 August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) and limited oral evaluation - problem focused (D0140) provided June 10, 2021.
You asked the Plan to pay for the cone beam CT capture. You say that you were unaware the provider had opted out of Medicare. The Plan denied your request. The Plan says the provider has opted out of Medicare and therefore 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. The Plan covers the cone beam CT capture when you receive the services from any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. We looked at the file and Medicare rules. The services at issue in this appeal were provided by a provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the cone beam CT capture have not been met. Therefore, we decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation with field of view of both jaws; with or without cranium (D0367) and limited oral evaluation - problem focused (D0140) provided June 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health speech therapy visits.
You asked the Plan to pre-approve home health. You say that continued speech therapy is needed to focus on cognitive-linguistic skills, motor speech exercises, expanding length of utterances, respiratory support for phonation, and home practice development to further stimulate expressive language functioning. The Plan denied your request. The Plan says the denial of authorization for additional home health visits is correct, because the records do not support the need for additional visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found the enrollee does not have ongoing home health speech therapy needs. The enrollee is months out from her stroke and has likely reached a plateau in function. Home health speech therapy is not medically 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 home health have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health speech therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for Neuropathy Support Supplement provided on
July 19, 2021.
You asked the Plan to reimburse you for the Neuropathy Support Supplement. You say that the pain in your legs and feet have decreased by 90% and you believe this supplement should be covered just as cranberry supplements and fish oil are covered. The Plan denied your request. The Plan says under the Pick Your Perks program, Neuropathy Support Supplement is not covered. The primary ingredients, Alpha Lipoic Acid,
L-Arginine HCI, as well as the proprietary blend are considered alternative medicine ingredients and not eligible under the Pick Your Perks program.
The Plan contract offers a supplemental Pick Your Perks program benefit. The benefit says over-the-counter items must be included on the Plan's allowed items list. We looked at the file and the Plan's rules. The file shows that over-the-counter items must be included on the
Plan's allowed items list. Ineligible items include but are not limited to the following: Alternative medicines such as botanicals, herbals, probiotics and nutraceuticals. The proprietary blend is considered alternative medicine ingredients and not eligible under the Pick Your Perks program. Therefore, we decided that the Plan does not have to reimburse you for Neuropathy Support Supplement provided on July 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract removal surgery with the insertion of lens (66984) rendered from April 28, 2021, to May 19, 2021.
You asked the Plan to waive the copayments for cataract removal surgery with the insertion of lens. You say that you were never told the cost for the surgical center for the cataract surgery would be $610. You also say that you believe you should not be responsible to pay that amount. 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 $350 copayment for freestanding Ambulatory Surgical Center for Outpatient Surgery, including services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers.
You have been asked to pay a $350 copayment for cataract removal surgery with insertion of lens on April 28, 2021. You have also been asked to pay a $350 copayment for cataract removal surgery with insertion of lens on May 19, 2021, which totals $700 ($350 + $350 = $700). Cataract removal surgery with insertion of lens 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 copayments for cataract removal surgery with the insertion of lens (66984) rendered from April 28, 2021, to May 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit (code 99282) provided on July 2, 2021.
You asked the Plan to waive the copayment for the emergency department visit. You say that the provider was not going to give you the care you needed, and that your doctor advised you to go to a different hospital. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency care visit. You have been asked to pay a $90 copayment for the emergency department visit. Emergency department visits fall 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 copayment for an emergency department visit (code 99282) provided on July 2, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal scaling and root planing provided on June 7, 2021.  You asked the Plan to pay for the periodontal scaling and root planing. You say that the doctor did not give you the services she billed for. You say that this is not ethical, and you should be compensated any money you had to pay. The Plan denied your request. The Plan says the service is not a covered 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 pay for the periodontal scaling and root planing provided on June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endodontic therapy for tooth #10.  You asked the Plan to pre-approve endodontic therapy. You say that the tooth is giving you a lot of pain, but the root canal was denied. The Plan denied your request. The Plan says the service is not a covered 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 endodontic therapy for tooth #10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial denture (D5214).
You asked the Plan to pre-approve the lower partial denture (D5214). The Plan denied your request. The Plan says the requested service is only covered once every five plan years.
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 one lower partial denture every five plan years. The Plan paid for the lower partial denture provided on May 19, 2017, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3-surface filling (D2332), 1-surface filling (D2330), and pulp cap (D3120) provided from April 30, 2021, to May 28, 2021.
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out of network. You say that the dental office advised they were in network. You also say that 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, care rendered by a provider that is not
part of our supplemental dental network is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 3-surface filling (D2332), 1-surface filling (D2330), and pulp cap (D3120) provided from April 30, 2021, to May 28, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the laboratory services provided on May 28, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan is denying payment stating the claim was submitted without the correct place of service (POS) code of 11 for office setting. However, the only claim the Plan provided shows that the claim was submitted with POS 11 correctly. The Plan did not provide a claim showing that POS 81 was submitted for payment. Therefore, we decided that the Plan has to pay for the laboratory services provided on May 28, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 2, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on December 1, 2020.  You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 1, 2020.