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

We decided that the Plan does not have to pay for the re-cement or re-bond unilateral space maintainer (D1553)
provided on April 3, 2021.

You asked the Plan to pay for the re-cement or re-bond unilateral space maintainer (D1553). You say that these
claims are the same procedure on different teeth, but the previous claim was approved. You say that the claim
for this tooth should be reviewed. The Plan denied your request. The Plan says the service is not a covered
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 the recement
or re-bond unilateral space maintainer (D1553) provided on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-rays and bitewing x-ray provided on May 18,
2021.

You asked the Plan to pay for the intraoral x-rays and bitewing x-ray. You say that dental x-rays have always
been part of the regular checkup. You say that you are surprised by the denial for the routine dental services.
The Plan denied your request. The Plan says the services 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 the
intraoral x-rays and bitewing x-ray provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922), and the unspecified adjunctive services (D9999 x 3) provided on March 12, 2021.

You asked the Plan to pay for the placement of intra-socket biological dressing and the unspecified adjunctive services. You say that you paid for these services because you were told they had to be covered by the medical plan. You say that the person in charge did not do the right thing in requesting pre-authorization for the services and using the wrong codes. You also say that the services should be covered. The Plan denied your request. The Plan says the placement of intra-socket biological dressing is not listed as covered service. The Plan says that the unspecified adjunctive services are not listed as covered services either.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the placement of intra-socket biological dressing and the unspecified adjunctive services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the placement of intra-socket biological dressing to aid in hemostasis or clot stabilization (D7922), and the unspecified adjunctive services (D9999 x 3) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on May 6, 2021.

You asked the Plan to pay for the dental service. You say that you believe you are covered for x-rays and a cleaning twice per year per your medical coverage. You say that you did not see any exceptions listed pertaining to types of x-rays. You also say that you cannot afford extra expenses. The Plan denied your request. The Plan says bitewing x-rays are not listed as 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 bitewing x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on May 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital observation services provided on May 30, 2020.

You asked the Plan to pay for the hospital observation services. You say that the patient was not already in a Hospice setting. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.

The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital observation services provided on May 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve interventional radiology to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve interventional radiology to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve interventional radiology to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the infiltration of sustained release therapeutic drug (D9613) or pay more for the problem focused limited oral evaluation (D0140), and surgical extraction (D7210) provided on April 9, 2021.

You asked the Plan to pay for the infiltration of sustained release therapeutic drug and to pay more for the problem focused limited oral evaluation, and surgical extraction. You say that the provider's office contacted the Plan and was advised that the extraction would be covered at 50%. The Plan denied your request. The Plan says the treating provider does not have a contract with the Plan as a participating provider and is allowed to bill the difference of the allowed amount and their billed amount to you. The Plan also says that the infiltration of sustained release therapeutic drug 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 infiltration of sustained release therapeutic drug (D9613) is not among those covered under this benefit. The contract also says that you are responsible for the difference between the billed amount and allowed amount for dental services received OON. Therefore, we decided that the Plan does not have to pay for the infiltration of sustained release therapeutic drug (D9613) or pay more for the problem focused limited oral evaluation (D0140), and surgical extraction (D7210) provided on April 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported porcelain/ceramic crown (D6058) for
tooth #14 provided on April 21, 2021.

You asked the Plan to pay for the abutment supported porcelain/ceramic crown. You say that you believe this
claim has been wrongfully denied because you have had this dental insurance for several years. The Plan
denied your request. The Plan says the installation of dentures, bridgework, or implants to replace missing teeth
or teeth that were lost before coverage began is not a benefit of the 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 initial installation of implants, full
or partial dentures or fixed bridgework to replace a tooth or teeth extracted prior to your effective date are
excluded from coverage. The record shows that tooth #14 was extracted on July 28, 2020, which is prior to
your effective date with this plan, and this service is not covered. Therefore, we decided that the Plan does not
have to pay for the abutment supported porcelain/ceramic crown (D6058) for tooth #14 provided on April 21,
2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on March 5, 2021.

You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for pathology services provided on March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from April 5, 2021, to April 12, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you believed this hospital stay would be no charge to you because it was related to COVID-19. The Plan denied your request. The Plan says the Plan's waiver for inpatient copayments related to COVID-19 ended on March 31, 2021. This copayment was applied 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 $275 copayment for each of the first five days of a Medicare-covered hospital stay. There is a $0 copayment for additional days.

You have been asked to pay a $1,375 copayment for a hospital stay that exceeded five days ($275 x 5 = $1,375). 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 inpatient hospital admission and services provided from April 5, 2021, to April 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray (D0220), prophylaxis (D1110), and resin-based composite (D2392) provided on April 6, 2021, and April 7, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, prophylaxis, and resin-based composite. You say that your insurance card says nothing about Medicare or opting out. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective March 9, 2016, to March 9, 2022. The Plan also says that you are responsible for services rendered by privately contracted providers.

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 pay for the periodic oral evaluation, first intraoral periapical x-ray (D0220), prophylaxis (D1110), and resin-based composite (D2392) provided on April 6, 2021, and April 7, 2021 by a Medicare opt out provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab services you received from an out-of-network provider on October 15, 2020.

You asked the Plan to waive the coinsurance for the lab services. You say that the pain clinic said they were not going to use your insurance card. You do not know what this bill is for. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You received drug testing lab services from this out-of-network provider.

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% of the Medicare-allowed amount for out-of-network lab services. 

You have been asked to pay 50% of the Medicare-allowed amount for the lab 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 coinsurance for lab services you received from an out-of-network provider on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a respiratory panel (87486, 87496, 87498, 87532, 87541, 87581, 87640, 87798) provided on November 30, 2020.

You asked the Plan to pay for a respiratory panel. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of a respiratory panel have not been met. Therefore, we decided that the Plan does not have to pay for a respiratory panel (87486, 87496, 87498, 87532, 87541, 87581, 87640, 87798) provided on November 30, 2020.
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not require services that can only be provided as an inpatient in a skilled nursing facility.
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 necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided by an out-of-network provider on
March 11, 2021.

You asked the Plan to pay for wound care. You say that the services were medically necessary and reasonable
for treatment based on the medical records. You say that you are requesting retroactive authorization and
payment based on medical necessity. The Plan denied your request. The Plan says there is no authorization for
services from a non-contract provider.

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 wound care provided by an out-of-network provider on March 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.

You asked the Plan to provide additional routine transportation. You say that you need additional transportation to get to your appointments. The Plan denied your request. The Plan says you have already used all of your routine transportation trips. Additional trips beyond 60 are not covered by your benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xarelto tablets.

You asked the Plan to pre-approve Xarelto tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Xarelto tablets are not covered under the enrollee's Medicare Part B 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 Xarelto tablets.

Benefits for Xarelto tablets 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the preventive procedure (D1999) provided on April 29, 2021.
You asked the Plan to pay for the preventive procedure. You say that you had a tooth that came out and the root
was still in your gums. You also say that it was painful, so you went to the dentist and had the root that was left
taken out. The Plan denied your request. The Plan says that your plan does not provide benefits for this service.
The Plan must follow Medicare rules. 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.
We found that you received a charge for the preventive procedure. Your 2021 EOC simply states that you have
a $1,500 annual allowance for preventive and comprehensive dental services every year. The EOC does not
clearly list the dental services that are covered by the Plan, nor does the record show that you have exhausted
your annual $1,500 dental allowance. You reasonably believed this service would be covered because it is not
listed as a non-covered dental benefit.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the preventive procedure have been met. Therefore, we decided that the Plan has to pay for the
preventive procedure (D1999) provided on April 29, 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.