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

We decided that the Plan does not have to pay for the 3-surface filling (D2393) for tooth # 15, and a 2-surface filling (D2392) for tooth # 31 provided on August 25, 2021.
You asked the Plan to pay for the fillings. You say that you have 3 fillings that contain mercury. You say that they need to be replaced with a resin-based composite. You say that the mercury causes lichen planus in your mouth to react with severe pain. You say that this has been going on for 3 years. You also say that your doctor recommended getting the fillings replaced. The Plan denied your request. The Plan says fillings are not covered 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the fillings are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 3-surface filling (D2393) for tooth # 15, and a 2-surface filling (D2392) for tooth # 31 provided on August 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) Deluxe frame (V2020)
miscellaneous vision item or service (V2799) provided June 12, 2021 to June 24, 2021.
You asked the Plan to pay for the vision services. You say that you did not receive any payment on the lenses
you purchased for $198.51. The Plan denied your request. The Plan says this item is not covered under the Plan
benefits.
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 1 pair of eyeglasses or contact lenses after each cataract surgery.
We looked at the file and the Plan's rules. The Plan covers 1 pair or eyeglasses or contact lenses after each
cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the vision services
have not been met. Therefore, we decided that the Plan does not have to pay for progressive lens, per lens
(V2781) Deluxe frame (V2020) miscellaneous vision item or service (V2799) provided June 12, 2021 to June
24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pin retention (D2951) provided on July 30, 2021.
You asked the Plan to pay for the pin retention. You say that you have a $1,000 allowance for comprehensive
dental services and do not see how this service is not considered basic restorative care that is covered. The Plan
denied your request. The Plan says this procedure is not covered under your dental 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, 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 pin
retention (D2951) provided on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a mammogram provided on August 12, 2021.
You asked the Plan to waive the copayment for the mammogram. You say that you feel there was an error in the first test and you should not be responsible for the copayment for a second test. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $95 copayment for diagnostic procedures and tests at an outpatient hospital facility, including diagnostic mammograms.
The file shows that your first mammogram showed abnormal findings. This second procedure was an in-depth, diagnostic test. Therefore, you have been asked to pay a $95 copayment for the mammogram. The mammogram falls 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 copayment for a mammogram provided on August 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Gemzar.
You asked the Plan to pre-approve Opdivo and Gemzar. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the requested drug.
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 Opdivo and Gemzar. Our reviewer says that 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. No literature from Medicare approved cancer journals were submitted for review. Our physician reviewer found the elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo and Gemzar have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo and Gemzar.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test(s) (G0480) provided on February 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug test(s). You say that you were not aware of the requirement of obtaining a prior authorization. You also say that you conducted the laboratory testing ordered by the referring provider in good faith, who deemed the services to be medically necessary. The Plan denied your request. The Plan says these services were rendered and referred by non-participating providers. The Plan also says that prior authorization was not 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 drug test(s) (G0480) provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for
coverage of LTACH services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee continues to receive acute care services and these have not been
denied. The medical record does not indicate that the enrollee requires services that she is not currently
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not
satisfied.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Partially Favorable

We decided that the Plan has to pay for the emergency ambulance services (A0425 and A0429). We decided that the Plan does not have to pay for the oxygen supplies (A0422).
You asked the Plan to pay for the emergency ambulance services (A0425 and A0429). You say that you would like reconsideration because the documentation submitted supports the diagnosis code billed and the medical necessity of the ambulance services. The Plan says that the diagnosis code does not match the services billed.
We decided that the Plan has to pay for the emergency ambulance services.
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has denied these services based on the diagnosis code billed. The Plan has not forwarded a claim or any evidence of what diagnosis codes were billed with the services at issue. Of note, Medicare does not provide specific rules regarding what diagnosis codes are appropriate for ambulance services. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the emergency ambulance services.
We also decided that the Plan does not have to pay for the oxygen supplies (A0422).
The Plan follows Medicare rules. Medicare rules say that payment for items and services is included in the fee schedule payment. We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage of the oxygen supplies have not been met. Specifically, payment for the oxygen supplies is included in the fee schedule payment for the ambulance services. Separate reimbursement is not made. Therefore, we decided that the Plan does not have to pay for the oxygen supplies (A0422).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
September 16, 2021.
You asked the Plan to pay for the dental service. You say that you made an appointment for a root canal. You
say that you were advised you should have the tooth pulled instead. You say that this provider did everything
but crown your tooth and then billed you for an examination that was not requested or necessary. You also say
that you feel you should be reimbursed for this service. The Plan denied your request. The Plan says 1
comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has
been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the
frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation
that you received on January 7, 2021, less than 3 years ago. Therefore, we decided that the Plan does not have
to pay for the comprehensive oral evaluation (D0150) provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), intraoral - periapical each additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and 3D photographic image (D0351) provided September 20, 2021, and September 24, 2021.
You asked the Plan to pay for the periodontal scaling and root planing, localized delivery of antimicrobial agents, additional intraoral x-rays, 2D oral photos and 3D photos. You say that these services are medically necessary. The Plan denied your request. The Plan says you have exceeded frequency limits for the intraoral x-rays and the remaining 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 the intraoral x-rays once per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that an intraoral x-ray was covered on September 20, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the additional intraoral x-rays has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the periodontal scaling and root planing, localized delivery of antimicrobial agents, 2D oral photos and 3D photos are not among those covered services. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing - four or more teeth per quadrant (D4341), localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381), intraoral - periapical each additional radiographic image (D0230), 2D oral/facial photographic image obtained intra-orally or extra-orally (D0350), and 3D photographic image (D0351) provided September 20, 2021, and September 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra.
You asked the Plan to pre-approve Xiidra. You say that this medication is medically necessary. The Plan denied your request. The Plan says this medication is not covered by 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 pre-approve Xiidra.
Benefits for Xiidra 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from
June 22, 2021, to September 22, 2021.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you used to pay less
each month and disagree with 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 20%
coinsurance for DME and related supplies.
You received DME and related supplies from June 22, 2021, to September 22, 2021. Therefore, you are
responsible to pay your share of the cost-sharing charges.
Date of Service Service Allowed Amount Amount You Owe
6/22/2021 DME and Related
Supplies
$55.59 $11.12
7/22/2021 DME and Related
Supplies
$55.59 $11.12
8/22/2021 DME and Related
Supplies
$55.59 $11.12
9/22/2021 DME and Related
Supplies
$55.59 $11.12
The total amount you owe is: $44.48.
You have been asked to pay the total coinsurance amount of $44.48 for DME and related supplies. DME and
related supplies fall within the 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 DME and related supplies provided from June 22, 2021, to September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care beyond the last
covered date of January 27, 2022.
You asked the Plan to pre-approve continued SNF care. You say that SNF care is medically necessary. The
Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of continued SNF care.
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 continued SNF care. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found daily skilled services are not
required. You do not require the services on an inpatient basis, only in a skilled nursing facility
setting. Services in a lower level of care would be more appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve skilled nursing facility (SNF) care beyond the last covered date of January 27,
2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on July 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the rendering provider is non-participating with the Plan and there is no referring provider. The Plan also says that prior authorization was not 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 domiciliary or rest home visit (99336) provided on July 13, 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 a home visit (99350) provided on September 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a home visit. You say that your physicians are hospitalists that rendered medical care for the patients in the hospital as requested by the hospital. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.
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 a home visit (99350) provided on September 22, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and unspecified preventive procedure, by report (D1999) provided October 15, 2021.
You asked the Plan to provide additional payment for the upper partial denture and unspecified preventative procedure. You say that your dental insurance was changed without your knowledge before you could finish your dental services. The Plan denied your request. The Plan says the claim has been reprocessed however you have exceeded your dental maximum and the unspecified preventative procedure 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. The Plan covers the upper partial denture up to the dental maximum of $2,500.
We looked at the file and Medicare rules. In this case the Plan provided documentation showing that at the time of the requested services you had $853 remaining in your dental allowance. This amount was applied to your partial denture. The remaining cost above the dental allowance is your responsibility. Though the Plan offers dental benefits in excess of Medicare coverage, the unspecified preventative procedure is not among those covered services. Therefore, we decided that the Plan does not have to provide additional payment for the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and unspecified preventive procedure, by report (D1999) provided October 15, 2021.