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

 We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided July 20, 2021.  You asked the Plan to pay for the dental consultation. You say that the dentist was in-network and was required to perform periodontal maintenance. The Plan denied your request. The Plan says this service is 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 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided July 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy, pathology services, and occupational therapy provided by a participating provider on June 11, 2021, to June 30, 2021.  You asked the Plan to waive the copayment for physical therapy, pathology services, and occupational therapy. You say that you do not know why you are being charged multiple copayments in one day. The Plan denied your request. The Plan says the correct copayments have been 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 $30 copayment for outpatient rehabilitation services.    You have been asked to pay a $30 copayment for physical therapy, pathology services, and occupational therapy. A separate copay for occupational therapy will apply if other outpatient therapy services are rendered on the same day. The total amount you are being asked to pay is $150 ($30 x 5 additional copayments = $150). Physical therapy, pathology services, and occupational therapy falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy, pathology services, and occupational therapy provided by a participating provider on June 11, 2021, to June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services provided on September 19, 2019.  You asked the Plan to pay for ambulance services. The Plan denied your request. The Plan says Medicare denies a claim if it is not received by the Plan within 12 months or 1 calendar year from the date when the services were rendered. The claims were received on July 15, 2021, which is past the allowed 12 month timeframe.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for ambulance services was not filed until July 15, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for ambulance services provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042), muscle and/or fascia debridement (11043), bone debridement (11044), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on July 28, 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 subcutaneous tissue debridement (11042), muscle and/or fascia debridement (11043), bone debridement (11044), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on July 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional five (5) home physical therapy visits.  You asked the Plan to pre-approve additional five (5) home physical therapy visits. You say that additional home physical therapy is medically necessary. The Plan denied your request. The Plan says additional home physical therapy is not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional five (5) home physical therapy visits. Our reviewer says that additional home physical therapy is not medically necessary or reasonable. Our physician reviewer found that based on the limited documentation provided, the health Plan's denial should be upheld. You do not have documented skilled therapy needs. As such, the requested, home physical therapy is not medically necessary or reasonable.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional five (5) home physical therapy visits. have not been met. Therefore, we decided that the Plan does not have to pre-approve additional five (5) home physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on July 13, 2021.  You asked the Plan to pay for the eye exam. You say that your vision changed months after cataract surgery, and you could no longer do close up work. You say that you went to your regular optometrist and agreed to not get another exam until October. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed for this type of service.  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 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 eye exam provided by an out-of-network provider on July 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the colonoscopy services with biopsy and lesion removal (45380, 45385) provided on May 27, 2021.  You asked the Plan to waive the copayment for the colonoscopy services. You say that your last colonoscopy was provided at the same facility by the same doctor and was covered in full. You do not understand why you are being charged for these services now. The Plan denied your request. The Plan says the provider billed this claim as a diagnostic colonoscopy, so the $400 copayment for a diagnostic colonoscopy applies rather than the $0 preventative screening colonoscopy benefit. This claim was processed 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 $400 copayment for a diagnostic colonoscopy performed in an outpatient hospital setting.  You have been asked to pay a $400 copayment for the colonoscopy services. The colonoscopy services were billed as diagnostic colonoscopy services and included removal of a lesion and a biopsy. These services are diagnostic in nature rather than a screening. A screening is performed as a check-up when there are no symptoms to investigate or cause for concern. A diagnostic test is performed to investigate symptoms and may include additional services. The colonoscopy services in this case were diagnostic and were performed 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 colonoscopy services with biopsy and lesion removal (45380, 45385) provided on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99335) 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 domiciliary or rest home visit for the evaluation and management of an established patient (99335) rendered by the out-of-network (OON) provider on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on August 7, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on August 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgently needed services provided on February 5, 2021.  You asked the Plan to waive the copayment for urgently needed services. You say that you cannot afford the charges. 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 $5 copayment for urgently needed services.   You have been asked to pay a $5 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on February 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the refraction provided on August 12, 2021.   You asked the Plan to pay for the refraction. You say that the Plan should pay this since this was a regular annual refraction. You say that you should be reimbursed in the amount of $26. The Plan denied your request. The Plan says eye refractions are only covered if performed by a participating provider and performed with a routine screening.  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 covers this service when it is performed with a routine eye exam from a participating provider.  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 eye refraction have not been met. Specifically, the refraction was not performed with a routine exam or received from a participating provider. Therefore, we decided that the Plan does not have to pay for the refraction provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), partial lower denture (D5214), and complete upper denture (D5110) provided from March 24, 2021, to May 10, 2021.  You asked the Plan to pay for the dental services. You say that your dentist retired in the middle of your treatment. You also say that despite paying for the services, you have not received any dentures. The Plan denied your request. The Plan says the topical application of fluoride varnish is not listed as a covered service. The Plan also says that dentures are not listed as covered services either.  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 topical application of fluoride varnish and dentures are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206), partial lower denture (D5214), and complete upper denture (D5110) provided from March 24, 2021, to May 10, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on June 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you were under the impression that the provider was in-network. The Plan denied your request. The Plan says no prior authorization was obtained.  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 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 office visit provided on June 18, 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 a dental crown (D2750), periodontal scaling and root planing (D4341), and an unspecified dental procedure (D4788).  You asked the Plan to pre-approve a dental crown, periodontal scaling and root planing, and an unspecified dental procedure. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the record does not contain sufficient documentation to establish medical necessity for the requested services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a dental crown and periodontal scaling and root planning 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 a dental crown and periodontal scaling and root planing. Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer found that the requested scaling and root planing for four quadrants is not supported by the supplied documentation. The provided X-rays show essentially intact bone levels in each quadrant with no exposure of root surfaces. Scaling and root planing in the presence of periodontal disease can only be performed where there is loss of clinical attachment and bone loss exposes previously covered root surfaces. Given the lack of any notable bone loss, the requested treatment would not be appropriate or medically necessary. The crowns requested for teeth #31 and #18 are not medically necessary. The provided X-rays reveal a two-surface restoration on tooth #31 that is relatively small and involves less than 25% of the tooth structure. Tooth #18 has no existing restoration and has small mesial surface caries. Neither tooth has any significant breakdown such that the teeth would need to gain strength by having a full coverage crown prepared. In general crowns are considered where there is more than 50% of the tooth structure missing or damaged and a conventional restoration would not be reasonably placed. Teeth #31 and #18 are not missing enough structure as to require full coverage crown restorations and they would not be reasonable or medically necessary.  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 a dental crown and periodontal scaling and root planing have not been met. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested unspecified dental procedure is not among the services covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental crown (D2750), periodontal scaling and root planing (D4341), and an unspecified dental procedure (D4788).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neuropathy support supplement purchased on August 19, 2021.  You asked the Plan to pay for the neuropathy support supplement. You say that you ordered the supplements and the pain decreased by over 90% without prescribed medication. You say that this works for you and the claim should be reconsidered for reimbursement. The Plan denied your request. The Plan says the neuropathy supplement, Alpha Lipoic Acid, is not listed as a covered item.  You have a $550 Pick Your Perks Benefit that is available for eligible over-the-counter items. The neuropathy support supplement is not listed as an eligible item. Therefore, we decided that the Plan does not have to pay for the neuropathy support supplement purchased on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 6, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you had an ongoing infection that antibiotics did not clear. 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 $35 copayment for specialist visits.   You have been asked to pay a $35 copayment for a specialist visit. A specialist visit 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 specialist visit provided on July 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided from August 15, 2021, to August 17, 2021.  You asked the Plan to waive the copayment for outpatient hospital observation. You say that you were waiting on a hospital bed. 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 $50 copayment for outpatient hospital observation.   The medical records show that you received outpatient hospital observation from August 15, 2021, to August 17, 2021. Therefore, you are responsible to pay the $50 copayment.  You have been asked to pay a $50 copayment for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from August 15, 2021, to August 17, 2021.