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

We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 21, 2021, by an out-of-network (OON) provider.

You asked the Plan to provide additional payment for the limited oral exam, intraoral x-rays and tooth extraction. You say that you were unaware that the provider was OON. The Plan denied your request. The Plan says the claims were processed correctly and paid up to the maximum allowable amount for an OON 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. The Plan covers the limited oral exam, intraoral x-rays and tooth extractions with a $0 copayment. If you choose to see an OON dentist you might be billed for charges about what the Plan pays, even for services listed as $0 copayment. 

We looked at the file and Medicare rules. In this case the Plan provided documentation showing that the Plan has covered the contracted amount for each service. Since the services were provided OON, you are responsible for the amount above what the Plan has paid. Therefore, we decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided September 21, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on April 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 13, 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 second pair of eyeglasses.   You asked the Plan to pre-approve a second pair of eyeglasses. You say that you need the strength of the glasses changed as your left eye is weak. You say that you don't need a second pair of glasses you only need the lenses covered. The Plan denied your request. The Plan says another pair of glasses is not medically necessary.  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 up to $200 per calendar year for eyewear without prior authorization.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of a second pair of eyeglasses have not been met. Specifically, the Plan already paid $286.98 for eyeglasses provided in February 2021. Therefore, we decided that the Plan does not have to pre-approve a second pair of eyeglasses.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.  You asked the Plan to pre-approve genicular radiofrequency ablation services. You say that this is medically necessary due to the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.  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 genicular radiofrequency ablation services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure and is the subject of ongoing clinical trials to determine its role in the management of knee osteoarthritis. Therefore, the request is deemed not medically reasonable or 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 genicular radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the partial upper denture (D5213) provided on June 14, 2021, by the out of network provider.
You asked the Plan to pay for the dental item. You say that you cannot afford the bill you received for $2,500 for the extraction and partial. The Plan denied your request. The Plan says dental items and services received 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, dental items and services received out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the partial upper denture (D5213) provided on June 14, 2021, by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the transthoracic echocardiography (TTE) you received on August 19, 2021.

You asked the Plan to reduce the copayment for the TTE. You say that you had other services at the same facility on September 1, 2021, and your copayment was lower. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the services you received on September 1, 2021, were completely different and have different cost sharing.

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 $100 copayment for diagnostic procedures and tests. 

You have been asked to pay a $100 copayment for the TTE. The TTE falls within the diagnostic procedures
and tests 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 reduce the copayment for the transthoracic echocardiography (TTE) you received on August 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the retainer crowns - porcelain fused to noble metal (D6752) and pontics - porcelain fused to noble metal (D6242) provided February 11, 2020.

You asked the Plan to pre-approve the retainer crowns and pontics. You say that similar services were covered with 50% coinsurance in previous years, and you feel they should be covered the same for 2020. The Plan denied your request. The Plan says these services 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 pre-approve the retainer crowns - porcelain fused to noble metal (D6752) and pontics - porcelain fused to noble metal (D6242) provided February 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self administered drugs provided in an outpatient setting on August 19, 201.

You asked the Plan to pay for the self administered drugs. You say that you were advised everything would be covered under the $325 copayment. You say that you do not feel you are responsible for the second copayment for the date of service. The Plan denied your request. The Plan says the drugs you received are considered self administered. The Plan says self administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self administered drugs provided in an outpatient setting on August 19, 201.

Benefits for the self administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF services.  

You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to skilled nursing facility does not meet the requirements for approval.  

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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT). You were at stand by assist/supervision to contact guard/minimal assist level with functional mobility including gait to 65 feet with a rolling walker. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and filling (D2392) provided from July 23, 2021, to August 27, 2021.

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that care rendered by a provider that is not part of our supplemental dental network 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, care rendered by a provider that is not part of our supplemental dental network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and filling (D2392) provided from July 23, 2021, to August 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a subcutaneous injection (a shot under the skin) that can be self-administered is covered by the pharmacy (drug) benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha SureClick for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the office visit you had with an out-of-network primary care doctor on February 17, 2021.

You asked the Plan to reduce the coinsurance for the out-of-network primary care visit. You say that you have spoken with this facility several times and they will not honor your insurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for out-of-network primary care visits.

You have been asked to pay 20% coinsurance for the out-of-network primary care visit. 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 reduce the coinsurance for the office visit you had with an out-of-network primary care doctor on February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan (J9312).

You asked the Plan to pre-approve Rituxan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules and is not covered based on available information.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

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 Rituxan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Rituxan is medically reasonable and necessary for the patient. There is no documentation that the Rituxan is safe and effective for the enrollee. The Medicare-approved major drug compendia do not support the use of Rituxan for the diagnosis of interstitial lung disease/nonspecific interstitial pneumonia. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (J9312).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for optometry services (92002) provided on August 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for optometry services. You say that the services should be covered as they were medically necessary The Plan denied your request. The Plan says the denial is correct as the services were provided by an out-of-network provider with no authorization or referral on file.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.     The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for optometry services (92002) provided on August 6, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve the SNF services. You say that it is dangerous for the enrollee to be by herself. You say that the enrollee's condition requires SNF care. The Plan denied your request. The Plan says the enrollee does not need skilled services on a daily basis. The Plan says that the enrollee can safely receive the care needed in a different setting.  

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter the enrollee does not require the necessary services on 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance response and treatment, no transport (A0998) provided June 29, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you did not call the ambulance and did not ask for any services. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance stabilization when there is not transport. You had 1 ambulance service. The Plan charged you $250 for these services. 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 ambulance response and treatment, no transport (A0998) provided June 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 25, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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
physical therapy services. 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 physical therapy services provided on
June 25, 2021.