Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 8, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you had a bad reaction to the coronavirus vaccine. 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment 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 copayment for ambulance services provided on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay more toward the frames and lenses. We decided that the Plan does not have to fully pay for the frames and lenses.
You asked the Plan to pay more for the frames and lenses. You say that the denial of payment was without merit and the maximum allowed was not exceeded. The Plan says that the maximum allowed under your benefit was exceeded.
We decided that the Plan has to pay more toward the frames and lenses.
The Plan contract clearly says that you have a $250 allowance every year for eyewear. According to the claim information submitted, the Plan paid $210 toward the frames and eye exam. This means that the Plan did not pay the full allowance toward the eyewear purchased. Therefore, we decided that the Plan has to pay up to the full $250 allowance for the frames and lenses.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on February 1, 2021.
You asked the Plan to pay for the home health 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Home health care services must be billed on a UB-04 form per Medicare guidelines. The case file shows the home health services were submitted incorrectly. Therefore, we decided that the Plan does not have to pay for the home health services provided on February 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 days of home health aide (HHA) visits, 2 hours per day.
You asked the Plan to pre-approve the requested number of HHA visits. You say that it is felt this should be covered. The Plan denied your request. The Plan says the three visits per week of skilled nursing visits are approved. However, HHA visits will not be required beyond 14 days.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 requested number of HHA visits. Our reviewer says that the documentation does not support the need for more than 14 days of HHA visits. Our physician reviewer found the documentation does not support that the HHA visits are medically necessary to support the ongoing skilled nursing care that was approved. These visits beyond the 14 days are 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 the requested number of HHA visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 60 days of home health aide (HHA) visits, 2 hours per day.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve occupational therapy. You say that the member would benefit from occupational therapy to address her chronic lower back pain. The Plan denied your request. The Plan says the requested provider does not participate in the Plan and therapy providers that participate in the enrollee's Plan that are available and accessible.

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 occupational therapy to be provided by the requested out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health services to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
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 mental health services to be rendered by the out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower partial denture.
You asked the Plan to pre-approve the upper and lower partial denture. You say that you need new dentures because your tooth is coming out and the dentures won't fit in your mouth. The Plan denied your request. The Plan says these services were provided to you on July 17, 2020, which exhausted your 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, complete and partial dentures are only covered once every 60 months. The Plan paid for the upper and lower partial denture provided on July 17, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic care provided on June 7, 2021, to July 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for chiropractic care. You say that you were not aware you needed authorization. The Plan denied your request. The Plan says this was not authorized.
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 chiropractic care provided on June 7, 2021, to July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says scaling and root planing is covered once per 3 years, per quadrant. 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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the frequency limit has been reached. The record shows that the Plan paid for scaling and root planing for the lower left and lower right quadrants that you received on June 9, 2021, and for scaling and root planing for the upper left and upper right quadrants that you received on June 10, 2021. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve periodontal scaling and root planing for all four quadrants.
You asked the Plan to pre-approve the requested periodontal scaling and root planing. You say that this is a necessary service. The Plan denied your request. The Plan says that there is not significant bone loss so this type of treatment is not necessary.
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 requested periodontal scaling and root planing when the services are medically necessary and reasonable. 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 requested periodontal scaling and root planing. Our reviewer says that the documentation supports that these periodontal services are medically necessary. Our physician reviewer found a review of the patient's dental record and radiographs indicate the presence of pathologic periodontal pockets (>4mm) in four quadrants. The presence of calculus formation was noted on radiographs. These findings warrant scaling and root planing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the requested periodontal scaling and root planing have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing for all four quadrants.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower
denture (D5120).
You asked the Plan to pre-approve the dental items. You say that the dentures you received in 2019 do not
work. You say that you cannot eat. You say that you went to court. You also say that the judge said to either fix
the dentures or refund you. The Plan denied your request. The Plan says dentures are covered once every 5 plan
years. 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental items have not been met. Specifically, the frequency limit has been reached. The record
shows that the Plan paid for a complete upper and complete lower denture that you received on December 23,
2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and
complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crowns (D6750) for a fixed bridge.
You asked the Plan to pre-approve the pontic (D6240) and retainer crowns (D6750). You say that you need the bridge. The Plan denied your request. The Plan says the use of double abutments is not approvable, nor are fixed bridges approvable when there are one or more missing posterior teeth in the same arch.
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 pontic (D6240) and retainer crowns (D6750) when the services are medically necessary and reasonable. 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 pontic (D6240) and retainer crowns (D6750). Our reviewer found that there would only be one tooth being replaced in the segment, however the plan is to use two abutment teeth to support the replacement tooth. Our reviewer says as there are missing posterior teeth in the same arch, the proposed use of double abutments, as well as poor periodontal health of those abutments, the criteria for a fixed anterior bridge has not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the pontic (D6240) and retainer crowns (D6750) have not been met. Therefore, we decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crowns (D6750) for a fixed bridge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the upper and lower partial denture.
You asked the Plan to pre-approve the upper and lower partial denture. You say that this is the second time your request for dentures was denied. The Plan denied your request. The Plan says your benefit is exhausted.
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 set of dentures every five years. The Plan paid for the upper and lower partial denture provided on May 2, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper and lower partial denture.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that you need approval
for three additional trips. The Plan denied your request. The Plan says you have exhausted this benefit for 2021.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers 18 one-way trips per year which have been exhausted. Extensions are not made to
supplemental benefit. Therefore, we decided that the Plan does not have to provide coverage for additional
routine transportation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and bitewing x-rays (D0274) provided from June 9, 2021, to June 10, 2021.
You asked the Plan to waive the out of network cost share for the dental services. You say that you were advised on a previous call that another doctor in the same office was participating. You also say that you assumed all of the doctors in that office would also be in network. The Plan denied your request. The Plan says the doctor in this case is out of network. The Plan also says that when you receive dental services out of network, you are responsible for balances up to the doctor's charge.
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, out of network doctors may bill you for any amount greater than what the Plan pays. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, the record shows that the Plan advised that a different doctor at a different location was in network. Therefore, we decided that the Plan does not have to waive the out of network cost share for the comprehensive oral evaluation (D0150), prophylaxis (D1110), and bitewing x-rays (D0274) provided from June 9, 2021, to June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation, per quadrant (D4921).
You asked the Plan to pre-approve the dental service. You say that this is medically necessary for treatment
underneath the primary gum line. The Plan denied your request. The Plan says this service is not covered under
the Plan 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
gingival irrigation, per quadrant (D4921).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (G0299) and skilled nursing visits for evaluation and management of the plan of care; each 15 minutes (G0162).

You asked the Plan to pre-approve home health visits. You say that you need a nurse. You say that you had neck surgery. You say that you chose to not go to a rehabilitation facility and get the services at home instead. You also say that you do not understand why the referral was denied since your provider requested it. The Plan denied your request. The Plan says home health requests must be certified by a doctor that they are medically necessary. The Plan also says that there are no orders from the doctor for the requested services.

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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health visits have not been met. Specifically, the file does not include an order from your physician for the requested services. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits (G0299) and skilled nursing visits for evaluation and management of the plan of care; each 15 minutes (G0162).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional naturopathic visits.
You asked the Plan to pre-approve additional naturopathic visits. You say that you chose this Plan because of their alternatives to major medical. You also say that you would like the Plan to raise your yearly limit of visits. The Plan denied your request. The Plan says the requested services exceed your benefit limit.
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for the services of a naturopath only up to six visits per year. We looked at the file and Medicare rules. Review of the file shows that you are covered for six naturopathy visits per calendar year. Based on this information, we decided that Medicare rules for coverage of additional naturopathic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional naturopathic visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 3, 2021, to May 7, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee was readmitted to the hospital 3 days after a previous stay for the same condition. You state that charges are supposed to be fully covered if an enrollee is readmitted to the hospital within 30 day for the same condition. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per admission for inpatient hospital care. The enrollee had an inpatient hospital stay from May 3, 2021, to May 7, 2021. This is considered a new inpatient hospital admission. Therefore, they are responsible to pay the $300 copayment.
The enrollee has been asked to pay a $300 copayment for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 3, 2021, to May 7, 2021.