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

 We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) provided by a participating provider.  You asked the Plan to pre-approve a mandibular partial denture. You say that a new partial denture is needed due to the original one being broken. The Plan denied your request. The Plan says the benefit for D5214 has already been 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. The Plan covers a mandibular partial denture once every five years.    We looked at the file and Medicare rules. D5214 has already been provided and is not available again until 2026. Based on this information, we decided that the Plan's rules for coverage of a mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and panoramic radiographic image (D0330) provided July 28, 2021.
You asked the Plan to pay for the tooth extraction and panoramic x-ray. You say that when you signed up the agent told you that you should submit your dental bills and they would be reimbursed in full. The Plan denied your request. The Plan says the services have been 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. The Plan covers one panoramic x-ray every five years. You may be billed by an out-of-network provider for any amount greater than the payment made by the Plan to the provider.
We looked at the file and Medicare rules. The Plan provided documentation showing a panoramic x-ray was previously covered on February 26, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the panoramic x-ray has been exceeded. The Plan also provided documentation showing that the extraction was covered up to the Plan's allowed amount. You are responsible for any cost over the amount the Plan paid to the provider. Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and panoramic radiographic image (D0330) provided July 28, 2021.
Your complaint about potentially receiving incorrect or incomplete information when you signed up for your dental benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309), the
subcutaneous tissue debridement (11042), the muscle and/or fascia debridement (11043), and the chemical
cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on August 30,
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 subsequent nursing facility care, per day (99309), the subcutaneous tissue
debridement (11042), the muscle and/or fascia debridement (11043), and the chemical cauterization of
granulation tissue (17250) rendered by the out-of-network (OON) provider on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids provided on May 17, 2021.  You asked the Plan to pay for the hearing aids. You say that the brand hearing aids were not recommended by your provider. You say that the claim should be processed out -of-network and you should be reimbursed $502. The Plan denied your request. The Plan says members must purchase brand hearing aids in order to use this benefit.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are brand hearing aids purchased from the Plan's hearing aid vendor.      We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on April 6, 2021, by the out of network dentist.
You asked the Plan to pay for the dental service. You say that you were given an list of network providers. You say that the list was not accurate. You say that you had no choice but to go out of network. You also say that contacting the plan was not an afterthought as you had done so multiple times before receiving this service. The Plan denied your request. The Plan says the provider in this case is not in network. The Plan says also that you must receive care in network in order for the services to be 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, the dental service received out of network is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on April 6, 2021, by the out of network dentist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on June 17, 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 initial nursing facility care, per day (99305) rendered by the out-of-network (OON) provider on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transvaginal ultrasound you had on June 14, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that when you joined this plan, you were told you would not have to pay for anything. You said that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic radiology services. You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls within the diagnostic radiology 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 transvaginal ultrasound you had on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the miscellaneous supply (Q0508) provided on April 30, 2021.
You asked the Plan to pay for code Q0508. 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 must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. In this case, there were no medical records provided to verify if the services were billed correctly per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the miscellaneous supply (Q0508) provided on April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a panniculectomy.  You asked the Plan to pre-approve a panniculectomy. You say that a panniculectomy is medically necessary. The Plan denied your request. The Plan says a panniculectomy 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 a panniculectomy. Our reviewer says that the requested panniculectomy is not considered medically reasonable and necessary. Our physician reviewer found that the medical record documents that your skin is normal. The records do not show that you are having trouble walking due to the panniculus, or that you have chronic skin irritation that has not responded to treatment over a period of three months. The health records received do not show documentation of dermatitis or the presence of a hernia. The photographs received do not clearly document the abdominal skin covering the pubis. Based on the current information, we have determined that the request for panniculectomy 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 a panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the cystoscopy procedure (51700, 52000) provided on May 19, 2021.  You asked the Plan to waive the copayment for the cystoscopy. You say that you were told this was a diagnostic procedure and would require no copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. You were provided with an outpatient surgical procedure in a hospital setting, which requires a $175 copayment.  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 $175 copayment for each Medicare-covered surgical procedure performed in a hospital-affiliated outpatient facility.   You have been asked to pay a $175 copayment for the cystoscopy. The cystoscopy procedure, billed with code 52000, is classified as a surgical procedure and was provided in an outpatient hospital setting. 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 cystoscopy procedure (51700, 52000) provided on May 19, 2021.   Your complaint about potential misinformation from a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99212) rendered by the out-of-network (OON) provider on June 14, 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 office visit (99212) rendered by the out-of-network (OON) provider on June 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and extraction (D7210) provided on July 6, 2021.  You asked the Plan to reimburse you for the dental services. You say that you started experiencing pain in one of your teeth over the weekend. You say that the dentist discovered your tooth was infected and needed to be extracted. You also say that this was an unusual situation, so you had to get it taken care of immediately. The Plan denied your request. The Plan says the dentist in this case is out of network. The Plan says that dental services must be performed by a participating general dentist to be 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, dental services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) and extraction (D7210) provided on July 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), and denture repair (D5511) provided on April 7, 2021, by the out of network dentist.  You asked the Plan to pay for the dental services. You say that you should not be charged for the panoramic x-ray as this was unnecessary. You say that you simply went in to drop off your denture so that it could get fixed. You say that you were advised that an exam and x-ray needed to be taken before they could send the denture to be repaired. You say that you feel this was fraudulent. You also say that you are not paying $1 for these services. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says out of network dentists may bill you for any amount greater than what the plan pays.  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 dentists may bill you for any amount greater that what the plan pays. 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 for the comprehensive oral evaluation (D0150), panoramic x-ray (D0330), and denture repair (D5511) provided on April 7, 2021, by the out of network dentist.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging you had on August 9, 2021.  You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that your doctor's office prescribed this test and told you that everything should be taken care of through insurance.  You said that had you known about the copayment, you would not have had the test. The Plan denied your request. The Plan says you were charged this copayment correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for diagnostic radiology services that are not ultrasounds.   You have been asked to pay a $325 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging falls within the diagnostic radiology services that are not ultrasounds 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 myocardial perfusion imaging you had on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 5, 2021.  You asked the Plan to pay for the panoramic x-ray. You say that you feel that the previous provider was doing unnecessary work and overbilling. You also say that you feel you should not be penalized and lose your once every 3-year use of the panoramic x-ray. The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.  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, panoramic x-ray (D0330) is limited to one procedure every three plan years. The record shows that you received a panoramic x-ray (D0330) on April 7, 2021 and your panoramic x-ray (D0330) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 5, 2021.   Your complaint about potentially being wronged by the previous dental provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient hospital facility on June 16, 2021.  You asked the Plan to waive the copayment for the lab services. You say that your Annual Notice of Change says that there is no copayment if lab services are performed as part of an office visit. The Plan denied your request. The Plan says this copayment applied correctly.  The Plan says that laboratory copayments do not apply if the office visit rendered on the same date of service already applied a copayment.  If a copayment did not apply to the office visit, the lab copayment would apply. The Plan says that the Annual Notice of Change letter states that laboratory services are $0 if performed as part of an office visit.  The Plan's intention is to prevent copayment stacking.  Since the annual physical that you had has no copayment for the office visit, the lab copayment does apply.  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 $10 copayment for lab services.   You have been asked to pay a $10 copayment for the lab services. Because you have not paid a copayment for a corresponding office visit on that same date of service, the lab copayment can apply. 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 lab services you received at an outpatient hospital facility on June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational
therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable
expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services