Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a back brace provided on August 23, 2021.

You asked the Plan to waive the coinsurance for the back brace. You say that you are unable to afford this copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 20% coinsurance for each durable medical equipment (DME) item, including back braces. 

You have been asked to pay $199.55, which is 20% of the allowed amount for the back brace. Back braces fall within the Durable Medical Equipment (DME) and Related Supplies 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 a back brace provided on August 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac surgery (33405, 33416, 33426) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the cardiac surgery. You say that the out-of-network provider has expertise in this procedure. The Plan denied your request. The Plan says there are available network providers who can perform the procedure at issue.

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 cardiac surgery (33405, 33416, 33426) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided May 27, 2021.

You asked the Plan to pay for the limited oral exam, intraoral x-rays and tooth extractions. You say that you have not been to the dentist in a long time and feel these services should be covered. The Plan denied your request. The Plan says these services are not covered under 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, 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 limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274) provided Jun 28, 2021, and the core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided July 27, 2021.
You asked the Plan to pay for the dental cleaning, periodic oral exam, bitewings, core buildup and crown. You say that the rules about opt-out providers are confusing and you cannot afford the cost of the services. The Plan denied your request. The Plan says the provider who rendered the services 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 certain dental services when you see 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 in a non-urgent, non-emergent situation 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 requested services have not been met. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), bitewings - four radiographic images (D0274) provided Jun 28, 2021, and the core buildup, including any pins when required (D2950) and crown - porcelain/ceramic (D2740) provided July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 21.

You asked the Plan to pre-approve the dental service. You say that your dentist advised that you need a crown for tooth # 21 as soon as possible. You say that you do not want to lose this tooth. You also say that you feel the service should be covered. The Plan denied your request. The Plan says crown is not listed as a covered service.

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 crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 21.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown repair necessitated by restorative material failure (D2980) and cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided August 12, 2021.
You asked the Plan to pay for the crown repair and cone beam CT scan. You say that you were told this provider was in-network and the Plan should cover it as such. The Plan denied your request. The Plan says the claims from this date of service have been reprocessed as in-network however, the crown repair and cone beam CT scan are not covered under your 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 pay for the crown repair necessitated by restorative material failure (D2980) and cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by a participating provider.

You asked the Plan to pre-approve dental implants. You say that you do not think it's fair that the Plan does not cover these types of implants. The Plan denied your request. The Plan says the dental services that the requested dental services 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. 

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 dental services to be provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the pneumatic compression device and appliance. You say that you are being denied because the provider is out of network and you are requesting this decision to be overturned. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says the requested compression sleeve is not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from April 16, 2021, to April 20, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that this hospital care was medically necessary, and you believe these copayments would be waived if you had gone to a different hospital. You feel the cost should be waived because you did not choose which hospital to go to. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. There is no provision in your contract about the waiver of inpatient copayments, and the hospital care is covered as it was medically necessary.

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 $240 copayment for each of the first seven days of an inpatient stay.

You have been asked to pay a $960 copayment for a four-day hospital stay ($240 x 4 = $960). 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 inpatient hospital admission and services provided from April 16, 2021, to April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on August 10, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says you must use a doctor in our hearing network.
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 provided by the Plan's participating hearing aid supplier. We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's participating hearing aid supplier. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on August 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 11, 2021, to July 12, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee was only in this facility for 19 hours before he was transferred to a different hospital, and you feel this was incorrectly submitted as an inpatient claim. The Plan denied your request. The Plan says this claim was billed and processed correctly as inpatient services for the dates in question, and the copayment was applied in accordance with the contract.
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 $343 copayment for each of the first four days of inpatient hospital care.
The enrollee has been asked to pay a $343 copayment for one day of inpatient care. Medical records support that inpatient care was provided and the enrollee was admitted as inpatient status. 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 the inpatient hospital admission and services provided from July 11, 2021, to July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had on August 24, 2021.

You asked the Plan to waive the copayment for the breast ultrasound. You say that this was supposed to be preventive due to dense breast composition. You also stated that Connecticut state law requires breast ultrasounds to be covered for patients with dense breast tissue. 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 $295 copayment for diagnostic radiology services. 

You have been asked to pay a $45 copayment for the breast ultrasound. The Plan has charged you this copayment stating that a $45 copayment applies to x-rays. However, an ultrasound is NOT an x-ray. An ultrasound is a diagnostic radiology service. According to your contract, you can be charged up to a $295 copayment for diagnostic radiology services. However, the Plan is only charging you $45. In addition, your contract says that the only breast screening test that is covered with no copayment is a mammogram. An ultrasound is not a mammogram. The cost sharing for an ultrasound is not waived even if needed for screening purposes or because you have dense breast tissue. There is no provision in your contract for a waiver of this copayment for any reason. In addition, the Connecticut law you referenced in your appeal regarding coverage of breast ultrasounds applies only to individual or group health insurance policies in the state of Connecticut. It does not apply to Medicare health plans. 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 breast ultrasound you had on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you received a denial that the supplies are not covered and you would like to appeal. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010 x 4), extractions (D7210 x 8), initial 15 minutes of deep sedation (D9222), additional 15 minutes of deep sedation (D9223 x 4), and therapeutic parenteral drug (D9610) to be provided by an out of network provider.

You asked the Plan to pre-approve the dental services. You say that the doctor has to use anesthesia if teeth are going to be extracted. The Plan denied your request. The Plan says dental services that you will receive out of network 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage and extractions are listed as covered, dental services to be received out of network are not covered. Additionally, the requested implants, deep sedation services, and therapeutic parenteral drug are not among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that the Plan does not have to pre-approve implants (D6010 x 4), extractions (D7210 x 8), initial 15 minutes of deep sedation (D9222), additional 15 minutes of deep sedation (D9223 x 4), and therapeutic parenteral drug (D9610) to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alignable system described by code L5910.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that when a preparatory below knee prosthesis is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment. 

We looked at the file and Medicare rules. The file shows that the Plan has approved a preparatory below-knee prosthesis with non-alignable system. The requested alignable system is therefore not compatible with the approved prosthesis and not covered. Therefore, we decided that the Plan does not have to pre-approve an alignable system described by code L5910.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be covered in an assisted living facility/long-term care setting as appropriate.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035).

You asked the Plan to pre-approve a custom breast prosthesis. You say that this would benefit the enrollee. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that the medical necessity for the additional features of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 breast prosthesis is billed, it will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. The item at issue has not been established as reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a custom breast prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom breast prosthesis (L8035).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 acupuncture visits.

You asked the Plan to pre-approve 12 acupuncture visits. You say that you were able to get in to see both physicians as needed for the request of acupuncture treatments. You say that the new notes should be reviewed, and the denial reconsidered. The Plan denied your request. The Plan says acupuncture is only covered with a diagnosis of chronic low back pain and services are only available in-network.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for chronic low back pain meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the requested provider is out-of-network. Therefore, we decided that the Plan does not have to pre-approve 12 acupuncture visits.