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

We decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
You asked the Plan to pre-approve radiofrequency ablation of the sacroiliac joint. 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 radiofrequency ablation of the
sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found radiofrequency ablation does not have sufficient
medical evidence to show long-term benefit for the enrollee's conditions and is not a standard of care for the
above conditions as such, especially if there is concurrent lumbar radiculopathy that is not corrected such as in
this case. Therefore, this request for radiofrequency ablation of the right sacroiliac joint will be considered not
medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiofrequency ablation of the sacroiliac joint have not been met. Therefore, we
decided that the Plan does not have to pre-approve radiofrequency ablation of the sacroiliac joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on January 27, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 the outpatient services provided on January 27, 2020 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on August 19,
2020.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says services rendered by non-participating providers required 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for outpatient services provided to the enrollee on
August 19, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home visit (99350), provided on February 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non emergent/urgent services by an out-of-network provider.
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 home visit (99350), provided on February 12, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for three additional resin-based fillings (D2393, D2392)
provided on November 17, 2020.
You asked the Plan to pay for the fillings. You say that you used an in-network provider and do not understand
why these services are not being covered. The Plan denied your request. The Plan says they have paid for two
of the five fillings you received on November 17, 2021. However, the Plan only covers a maximum of two
restorations (fillings) per year. You are responsible for the remaining three fillings as these exceed your benefit
limitations.
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 can cover up to two
restorations (fillings) per year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested fillings exceed what is
covered under this benefit. Documentation shows that the Plan covered two of the fillings you received on the
same date, and therefore your benefit maximum for restorations has been met and exceeded. Therefore, we
decided that the Plan does not have to pay for three additional resin-based fillings (D2393, D2392) provided on
November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a partial lower denture (D5214) provided on March 12, 2021.
You asked the Plan to pay an additional amount for the dental service. You say that you have $2,000 coverage for dental services. You say that you were never given the details of your coverage beyond that. You also say that times are very tough for you. The Plan denied your request. The Plan says you pay a 70% coinsurance for dentures that you receive in network. The Plan says that 30%, or $416.10, was paid towards the partial lower denture. The Plan also says that the claim was processed correctly.
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 partial lower denture is listed as covered, there is a 70% coinsurance when you receive this service in network. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for a partial lower denture (D5214) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230) provided
on May 20, 2021.
You asked the Plan to pay for the inhalation of nitrous oxide/analgesia. You say that you have to use nitrous.
You also say that you cannot afford to pay for this service out of pocket. The Plan denied your request. The
Plan says benefits for this service are not available.
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 contract says that facility and/or
facility anesthesia services associated with a dental procedure are covered only if the primary dental procedure
is covered under the guidelines of Original Medicare. Resin-based composites (fillings) are clearly listed as
non-Medicare covered (or supplemental) dental services, and are not considered to be Medicare-covered.
Therefore, we decided that the Plan does not have to pay for the inhalation of nitrous oxide/analgesia (D9230)
provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on May 10,
2021.
You asked the Plan to waive the copayment for these services. You say that the provider is not a specialist. The
Plan denied your request. The Plan says the copayment was 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 a $30
copayment for Medicare-covered specialist services.
Review of the file shows that you received specialist services from a physiatrist on May 10, 2021. You have
been asked to pay a $30 copayment for these services. These services fall within the Medicare-covered
specialist 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 the specialist
services rendered on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy (D3425) and retrograde filling (D3430) provided on May 5, 2021.
You asked the Plan to pay for the endodontic services. You say that these services were necessary and feel the retrograde filling should be covered as a root canal retreatment. The Plan denied your request. The Plan says these services are 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. The Plan can cover the following endodontic services: root canal therapy on permanent teeth, including pulpotomies, indirect pulp-cap, and root canal retreatment (mutually exclusive of final restoration). 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.
You requested that the retrograde filling be covered as a root canal retreatment. However, these are two different services, and the service provided and billed is a retrograde filling. Therefore, we decided that the Plan does not have to pay for the apicoectomy (D3425) and retrograde filling (D3430) provided on May 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam (92014) provided on June 25, 2021.
You asked the Plan to waive the copayment for a medical eye exam. You say that this appointment should have been the last post-operative visit after your cataract surgery. The last post-operative visit you had scheduled originally was for April 22, 2021, but because of your reaction to the vaccine, they rescheduled you for June 25, 2021. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $40 copayment for a medical eye exam. The records show that you had a 90-day post-operative period after your cataract surgery. The records also show that your office visit took place outside of the 90-day post-operative period. The EOC confirms that $40 is the required copayment for this service. A medical eye exam 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 medical eye exam (92014) provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blepharoplasty (15823) and lid lesion removal (67840) 
to be provided at an OON facility. 
 
You asked the Plan to pre-approve a blepharoplasty and lid lesion removal. You say that these services are 
medically necessary. The Plan denied your request. The Plan says they have in-network facilities that are able 
to host the surgery. 
 
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 facility in this case is not contracted with the Plan. The Plan has network facilities 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 at an OON facility. Therefore, we decided that the Plan does not have to pre-
approve a blepharoplasty (15823) and lid lesion removal (67840) to be provided at an OON facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the refraction provided on May 12, 2021.
You asked the Plan to pay for the refraction. You say that the refraction would have been covered if the provider had submitted the claim correctly. You say that you shouldn't be penalized and have to pay the cost. The Plan denied your request. The Plan says this is not a Medicare covered service. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan and Medicare do not cover this service. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the refraction provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neck surgery with allograft.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no severe stenosis or instability on imaging. Also, there is no documentation of a recent trial and failure of adequate conservative measures, to include physical therapy.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve neck surgery with allograft.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy provided on October 30, 2020 by a nonparticipating
provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 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 the colonoscopy provided on October 30, 2020 by
a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 
17, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 services provided by an out-of-network provider on May 17, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 25, 2021.
You asked the Plan to pay for the services. 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 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 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 services provided by an out-of-network provider on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit services (99205, 99215) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit services. You say that this care is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide the care you need.
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 an office visit services (99205, 99215) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmological medical examination
and evaluation (92012) and the scanning computerized ophthalmic diagnostic imaging (92134) provided on
April 10, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for specialist physician services. Additionally, you must pay a $50 copayment for all other
Medicare-covered outpatient diagnostic tests. You have been asked to pay $93.22 which includes a $45 copayment for the specialist physician services
provided. Additionally, this amount includes a $48.22 copayment for the Medicare-covered outpatient
diagnostic test provided; this is the Plan's allowed amount for this service which is less than the applicable
copayment. 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 ophthalmological medical examination
and evaluation (92012) and the scanning computerized ophthalmic diagnostic imaging (92134) provided on
April 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation (A0429, A0425) provided on December 31, 2020.
You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you were not aware that the services would not be covered in full. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $395 copayment for ambulance services. The enrollee has been asked to pay $359.45 copayment for emergency ambulance transportation. The services at issue fall within the ambulance services benefit category. Since the Allowed Amount for this service is less than the required copayment of $395, the enrollee has been asked to pay only $359.45. 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 emergency ambulance transportation (A0429, A0425) provided on December 31, 2020.