Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services provided from March 3, 2021, to May 31, 2021.
You asked the Plan to waive the coinsurance for the dialysis services. The enrollee stated that they could not afford this coinsurance. The Plan denied the request. The Plan says this coinsurance was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for dialysis services. The enrollee has been asked to pay 20% coinsurance for the dialysis services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for dialysis services provided from March 3, 2021, to May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 2, 2021, by a nonparticipating
provider.

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 services were rendered by a non-participating 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 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 the physician services provided on March 2, 2021,
by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical radiographic images (D0220, D0230) provided on April 15, 2021.

You asked the Plan to pay for intraoral periapical radiographic images. You say that you thought the provider was in-network. The Plan denied your request. The Plan says the services at issue are not covered 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 intraoral periapical radiographic images (D0220, D0230) provided on April 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc for the enrollee.
You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is medically necessary for the enrollee.
The Plan denied your request. The Plan says that medical necessity criteria is not met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Orthovisc. Our reviewer says that
Orthovisc is not medically reasonable and necessary for the enrollee. The enrollee has x-ray evidence of
narrowing of the joint space with degenerative joint changes. He has tried and failed Naproxen and one
cortisone injection. There has been no failure of 3 months of conservative care such as physical therapy or any
other trial of another NSAID. Our physician reviewer found that the enrollee's condition does not meet criteria
for Orthovisc.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Orthovisc for the enrollee
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve scaling and root planing (D4341) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that you have a lot of build up on your teeth. You also say that you have pockets that need to be managed. The Plan denied your request. The Plan says that the scaling and root planing are not medically necessary.
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 dental services 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 the dental services. Our reviewer says that the scaling and root planing for all 4 quadrants are medically necessary. Our physician reviewer found the provided documentation indicates that periodontal pocket depth of 4 to 5 millimeters is present in all quadrants. The reviewer found that the requested periodontal scaling and root planing in the 4 quadrants is medically reasonable and 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 the dental services have been met. Specifically, the file indicates that the pocket depth of 4 to 5 millimeters is present in all 4 quadrants. Therefore, we decided that the Plan has to pre-approve scaling and root planing (D4341) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), a cup holder (K0108), and a transit system (K0108) for a power wheelchair.

You asked the Plan to pre-approve an electronic connection, a cup holder, and a transit system. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.

We decided that the Plan does not have to pre-approve an electronic connection:

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 an electronic connection. Our reviewer says that the electronic connection coded E2311 is not medically necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee requires other types of proportional input devices (for example, mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (for example, sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (that is, for alternate control devices), other electronic devices (for example, control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed self indicates that the enrollee can control any power options through their own individual switches.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311).

We decided that the Plan does not have to pre-approve a cup holder:

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

A cup holder does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a cup holder (K0108).

We decided that the Plan does not have to pre-approve a transit system:

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

A transit system is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit system (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for full mouth debridement to enable a comprehensive oral evaluation on a subsequent visit (D4355) provided on May 6, 2021.
You asked the Plan to pay for full mouth debridement. You say that you arrived for a standard cleaning and told the provider that you did not want a deep root cleaning. They gave you the service anyway and gave you the bill after the fact. The Plan denied your request. The Plan says this service is not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for full mouth debridement to enable a comprehensive oral evaluation on a subsequent visit (D4355) provided on May 6, 2021.
Your complaint about potential issues with the care provided by a Plan-contract provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a rest home visit (99336) provided on March 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a rest home visit. You say that authorization was the facility's responsibility. The Plan denied your request. The Plan says this was not authorized.
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 rest home visit (99336) provided on March 16, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for outpatient surgery you had at an out-of-network ambulatory surgery center on October 14, 2020.

You asked the Plan to reduce the cost sharing for the out-of-network surgery. You say that you were told prior to the surgery that you would only owe $200 for this procedure. The Plan denied your request. The Plan says you were charged this 50% coinsurance correctly because you used an out-of-network ambulatory surgery center. The $200 copayment only applies when you use network facilities.

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 50% coinsurance for outpatient surgery at an out-of-network ambulatory surgery center.

You have been asked to pay 50% coinsurance for the out-of-network surgery. This facility is not a network facility with the Plan. 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 cost sharing for outpatient surgery you had at an out-of-network ambulatory surgery center on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot
be verified.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.

We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the brachytherapy procedure and related services you had at an outpatient hospital facility on December 11, 2020.
You asked the Plan to waive the copayment for the brachytherapy procedure. You say that you do not agree with this copayment. The Plan denied your request. The Plan says this copayment was charged 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 $200 copayment for outpatient hospital services. You have been asked to pay a $200 copayment for the brachytherapy procedure. The brachytherapy procedure falls within the outpatient hospital 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 the brachytherapy procedure and related services you had at an outpatient hospital facility on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 6, 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 office visit (99214) rendered by the out-of-network (OON) provider on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on February 25, 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 services are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.

We looked at the file and Medicare rules. Billed procedure codes S101 (IV tubing extension set) and S8301
(infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we
decided that the Plan does not have to pay for the supplies rendered on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the duplex scan you had on January 6,
2021.
You asked the Plan to waive the coinsurance for the duplex scan. You say that you were told you only owed
$4.47 for the test you had on January 6, 2021, so you don't understand why the amount you are now being
charged is different. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The Plan also says that it has already adjusted the copayment for the office visit you had on January 5, 2021, to
$5, so that is no longer in dispute.
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 diagnostic procedures and tests.
You have been asked to pay 20% coinsurance for the duplex scan. The allowed amount for this duplex scan is
$106.46, so 20% coinsurance equals $21.29. The duplex scan 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 waive the coinsurance for the duplex scan you had on
January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body (D6010 x 2) provided on April 14, 2021.
You asked the Plan to pay for the implants. You say that your previous claim for service performed by the same dentist were processed as in network. You say that you were not informed that the dentist was not in network anymore. You also say that you were not informed that the services on this date of service would not be covered. The Plan denied your request. The Plan says surgical placement of an implant body is not listed as a covered service. The Plan also says that the previous claim was covered as a one-time exception due to coronavirus.
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 surgical placement of an implant body is not among those covered under this benefit regardless of the provider's network status. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body (D6010 x 2) provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 1, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you have received services from this provider in the past and you were reimbursed. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective February 10, 2016, to February 10, 2022. The Plan also says that payment cannot be made for services performed by a provider who has opted out of 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 provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on April 1, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the deductible for a telehealth practitioner visit on January 14, 2021. We decided that the Plan does not have to waive the coinsurance for telehealth practitioner visits and psychotherapy services provided from January 14, 2021, to April 8, 2021.
You asked the Plan to waive the deductible and the coinsurance for telehealth practitioner visits and psychotherapy services. You say that you were told that coinsurance payments were waived for therapy via telehealth. You say you were never notified that the waived coinsurance payments ended. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount
We decided that the Plan has to waive the deductible applied to a telehealth practitioner visit.
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 the deductible does not apply to telehealth services. Therefore, we decided that the Plan has to waive the deductible applied to the telehealth practitioner visit on January 14, 2021.
We also decided that the Plan does not have to waive the coinsurance for telehealth practitioner visits and psychotherapy services provided from January 14, 2021, to April 8, 2021.
Your contract with the Plan clearly says that you must pay 10% coinsurance for telehealth practitioner visits and psychotherapy services. You have been asked to pay a total of $107.58, which is 10% coinsurance of the allowed amount for telehealth office visits and psychotherapy services.
Claim Number:
Date of Service:
Allowed Amount:
10% Coinsurance
031804325
1/14/2021
$126.94
$12.69
032156288
1/28/2021
$168
$16.80
032771875
2/11/2021
$150
$15.00
032999792
2/25/2021
$168
$16.80
033509237
3/11/2021
$126.94
$12.69
033934488
3/25/2021
$168
$16.80
034355241
4/8/2021
$168
$16.80
Total:
$1075.88
$107.58
Therefore, we decided that the Plan does not have to waive the coinsurance for telehealth practitioner visits and psychotherapy services provided from January 14, 2021, to April 8, 2021.
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.