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

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) provided April 27, 2021.

You asked the Plan to pay for the comprehensive periodontal exam. You say that you would like the service covered. 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 comprehensive periodontal evaluation - new or established patient (D0180) provided April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the consultation (D9310) and removal of residual tooth roots (D7250) provided on May 24, 2021, by an out of network dentist.

You asked the Plan to pay an additional amount for the dental services. You say that you contacted the plan in May 2021 to check for in network dentists. You also say that you feel you were given misleading information. The Plan denied your request. The Plan says consultation is not listed as a covered service. The Plan says there is a 50% coinsurance for removal of residual tooth roots. The Plan also says that out of network dentists may bill you for any amount greater than what the plan pays the provider.

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 consultation is not among those covered under this benefit. There is a 50% coinsurance for removal of residual tooth roots that applies to the maximum allowable charge (MAC) of $128. $128 x 50% = $64. Additionally, out of network providers may bill you for any amount greater than what the plan pays the provider. $488 - $64 = $424. Therefore, we decided that the Plan does not have to pay an additional amount for the consultation (D9310) and removal of residual tooth roots (D7250) provided on May 24, 2021, by an out of network dentist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the lumbar spine (72100) rendered by the out-of-network (OON) provider on May 19, 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 x-ray exam of the lumbar spine (72100) rendered by the out-of-network (OON) provider on May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 24, 2020.
You asked the Plan to pay for the dental services. You say that you do not understand why they told you they accepted your insurance. You say that you had no idea they were not participating, and you should be reimbursed $220. The Plan denied your request. The Plan says a provider who is not eligible to participate in Medicare cannot be paid.
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 provider is federally debarred and not eligible for payment. Therefore, we decided that the Plan does not have to pay for the dental services provided on November 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 21, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you did not receive any care. 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 $90 copayment for emergency care. 

The medical records show that you received emergency care on February 21, 2021. Therefore, you are responsible to pay the $90 copayment. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on February 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi.
You asked the Plan to pre-approve Imfinzi. You say that Imfinzi has been approved as a maintenance therapy The Plan denied your request. The Plan says the effectiveness of Imfinzi in the setting of squamous cell lung cancer has not been demonstrated.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. The file shows that Imfinzi to be used with Cinvanti and Dexamethasone was requested. 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 Imfinzi. Our physician reviewer found that in this case, the record indicates the enrollee has squamous cell lung cancer. stage 1B. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services and laboratory services
provided from June 11, 2021, to June 12, 2021.
You asked the Plan to waive the copayments for specialist services and laboratory services. You say that you
already paid the surgical copayment and disagree with the additional 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 $40
copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $10
copayment for laboratory services.
You received specialist services on June 11, 2021. Therefore, you are responsible to pay the $40 copayment.
You received specialist services on June 12, 2021. Therefore, you are responsible to pay the $40 copayment.
You received laboratory services on June 11, 2021. Therefore, you are responsible to pay the allowed amount
of $7.28, which is less than the $10 copayment.
The total amount you owe is: $87.28.
You have been asked to pay the total copayment amount of $87.28 for specialist services and laboratory
services. Specialist services fall within the physician/practitioner services, including doctor's office visits
benefit category. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and
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 copayments for specialist services and
laboratory services provided from June 11, 2021, to June 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TAVR (CPT code 33361), for the enrollee.
You asked the Plan to pre-approve TAVR. You say that the service is medically necessary. The Plan denied your request. The Plan says TAVR is not a covered benefit because you do not have aortic valve stenosis.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TAVR have not been met. TAVR is not a covered benefit because the enrollee does not have aortic valve stenosis. Therefore, we decided that the Plan does not have to pre-approve TAVR (CPT code 33361), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport provided on March 30, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that an ambulance was called by the enrollee's primary care physician due to a change in status, including an onset of slurred speech. You also say that upon arrival the enrollee refused to be transported. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 30, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport provided on March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth extraction (D7140) provided on May 24, 2021.
You asked the Plan to pay for the extraction. You say that you were not informed that the office did not accept Medicare payment. The Plan denied your request. The Plan says that the provider in this case is opted-out of Original Medicare. Payment cannot be made for these services based on your contract.
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. To use your supplemental dental benefits, you may see any licensed dental provider who accepts Medicare patients in the United States and has not opted-out of Original Medicare. If you use a provider that has opted-out of Medicare, you will not receive reimbursement. Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from providers who have opted-out of Original Medicare are not covered under this benefit. Documentation shows that the provider in question does not participate with Original Medicare. Documentation provided for review also includes a form provided by the provider's office with your signature. This form states that you agree to be
fully responsible, through insurance or otherwise, for payment of services rendered by this provider, and you understand that no claims will be submitted to Medicare and no Medicare reimbursement will be provided for these services. Therefore, we decided that the Plan does not have to pay for the tooth extraction (D7140) provided on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) provided on May 24, 2021.

You asked the Plan to pay for the oral hygiene instructions. You say that you got this treating provider's number from the Plan's list and believe this provider was in-network. The Plan denied your request. The Plan says this service is 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, 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 oral hygiene instructions (D1330) provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies provided on March 24, 2021.

You asked the Plan to waive the coinsurance for prosthetic devices and related supplies. You say that you were told that the device would be fully covered. 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 20% coinsurance for prosthetic devices and related supplies. 

You received prosthetic devices and related supplies on March 24, 2021. The total allowed amount is $8,593.81 and 20% of that is $1,718.75. 

You have been asked to pay the total coinsurance amount of $1,718.75 for prosthetic devices and related supplies. Prosthetic devices and related supplies fall within the prosthetic devices 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 prosthetic devices and related supplies provided on March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 14, 2021.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on March 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210), primary closure of a sinus perforation (D7261), bone replacement graft for ridge preservation (D7953), deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral drug (D9610) to be rendered by a Medicare opt out provider.
You asked the Plan to pre-approve the surgical extraction, primary closure of a sinus perforation, bone replacement graft, deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral drug. You say that you cannot find any providers who participate with your plan. The Plan denied your request. The Plan says the provider you have requested to render these services does not participate with Medicare.
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 covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210), primary closure of a sinus perforation (D7261), bone replacement graft for ridge preservation (D7953), deep sedation/general anesthesia (D9222 and D9223), and therapeutic parenteral drug (D9610) to be rendered by a Medicare opt out provider.
Please Note: The Plan confirmed that there are no participating dental providers within your area. The Plan also says that it is recommended to make an exception to allow you to go to an out-of-network oral surgeon who has not opted out of Medicare coverage. Please contact the Plan for more information.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (99053) provided to the enrollee on January 4, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code has a status indicator of "B."
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99053 is "Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service." We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the denied code has a status indicator of "B" - which means bundled code. Payment for this code is always bundled into payment for other services not specified. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident.
We looked at this coder'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 pay for hospital services (99053) provided to the enrollee on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-rays and extractions provided on April 28, 2021.

You asked the Plan to pay for the limited oral evaluation, intraoral x-rays and extractions. You say that you have seen the provider before and figured you wouldn't have to do a consultation. You say that they told you before the appointment was made that they accepted your insurance. The Plan denied your request. The Plan says out-of-network dental 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental 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, intraoral x-rays and extractions provided on April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 6, 2021, to March 30, 2021.
You asked the Plan to pay for the SNF care provided from March 6, 2021, to March 30, 2021. You say that the services are coverable by the Medicare Act. The Plan denied your request. The Plan says the care provided on the dates of service in this case are custodial in nature. The Plan says that there is no added benefit for custodial care that goes beyond the Medicare benefit. The Plan says that because there is no Medicare benefit or health plan added benefit for custodial care, coverage cannot be provided.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from March 6, 2021, to March 30, 2021, have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from March 6, 2021, to March 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional prophylaxes (D1110 x2).
You asked the Plan to pre-approve the prophylaxes. You say that the enrollee needs to be seen every three months to avoid plaque buildup that would cause attachment loss and larger issues. The Plan denied your request. The Plan says these services do not meet the frequency requirements of the Plan.
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, prophylaxis (D1110) is limited to two procedures per plan year. The record shows that you have requested the enrollee receive four prophylaxes (D1110 x4). The additional two prophylaxes cannot be approved because the enrollee will have exhausted their prophylaxis (D1110) benefit. Therefore, we decided that the Plan does not have to pre-approve two additional prophylaxes (D1110 x2).