Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED services provided from August 4, 2019 through August 10, 2019 and the CT scan provided on August 29, 2019.
You asked the Plan to waive the copayment for the ED services and CT scan. You say that she was admitted to the hospital. You say that the copayment should be less. The Plan denied your request. The Plan says the copayments 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency services in an emergency room and a $50 copayment for advanced imaging services at an in-network outpatient hospital. The enrollee has been asked to pay a $120 copayment for the ED services and a $100 copayment for the CT scan. The ED services fall within the "Emergency care" benefit category. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The total amount you owe is $220 ($120 + $100 = $220). The records show that the services were provided on an outpatient basis.
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 copayment for the ED services provided from August 4, 2019 through August 10, 2019 and the CT scan provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hepatitis A and B vaccine (90636), a typhoid vaccine (90691), and administration (99401 and 90471) provided on October 21, 2019.
You asked the Plan to pay for a hepatitis A and B vaccine, a typhoid vaccine, and administration. You say that you needed these vaccines due to traveling out of the country. The Plan denied your request. The Plan says coverage of these vaccines is the responsibility of your Part D plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a hepatitis A and B vaccine, a typhoid vaccine, and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a hepatitis A and B vaccine, a typhoid vaccine, and administration. Therefore, we decided that the Plan does not have to pay for a hepatitis A and B vaccine (90636), a typhoid vaccine (90691), and administration (99401 and 90471) provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lower partial denture (D5214).You asked the Plan to pre-approvethe dental service. You say that the enrollee's current partial denture is ill fitting. You say that due to the enrollee's health, there is a medical risk involved if her teeth are extracted for a full denture. You also say the enrollee needs a new partial to keep up her strength for health reasons.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says the frequency limit has been reached.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 coverageand a lower partial denture is listed as covered, thefrequency limit has been reached.The record shows that the Plan paid for a lower partial denture that you received on February 23, 2016, less than 5 years ago.Therefore, we decided that the Plan does not have to pre-approvea lower partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the seat lift mechanism of a seat lift chair provided on September 18, 2019 by an out of network provider. Medicare does not cover the upholstered portion of a seat lift chair. You asked the Plan to reimburse you for the seat lift mechanism of a seat lift chair. You say that you needed a seat lift chair because you cannot get up and down from sitting. The Plan denied your request. The Plan says the supplier does not participate in Medicare.
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 rules say that a seat lift mechanism is covered if all of the conditions listed above are met. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. There is no physician order. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to reimburse you for the seat lift mechanism of a seat lift chair provided on September 18, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and an amalgam (D2160).
You asked the Plan to pre-approve the dental services. You say that you had half of your dental work done. You say that when you went back to get the dental work finished, your policy had ended. You say that the work had already been approved and you just want to get it done with the coverage that you had. You also say that your teeth hurt and you cannot wait for them to keep decaying. The Plan denied your request. The Plan says the requested crown and amalgam 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 crown and amalgam are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) and an amalgam (D2160).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses & lumbar-sacral orthosis provided on September 26, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and lumbar-sacral orthosis (L0648). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no itemized shipping/billing invoice to indicate the specific supplies or Proof of Delivery indicating the billed items were delivered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Also, the claim date of service is neither the shipping date or delivery date. Therefore, we decided that the Plan does not have to pay for the knee orthoses and lumbar-sacral orthosis provided on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on October 31, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that the X-ray was taken as a follow-up to a procedure and you 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 a $35 copayment for X-rays. You received an X-ray on October 31, 2019. X-rays are not included in follow-up visits. Therefore, you are responsible to pay the allowed amount of $30.68, which is less than the $35 copayment. You have been asked to pay $30.68 for an X-ray. An X-ray 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 an X-ray provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic casts, endodontic therapy, three core buildups, including any pins when required, additional crown, and two alveoloplasties in conjunction with extractions provided from October 24, 2019 to November 11, 2019.
You asked the Plan to pay for the diagnostic casts, endodontic therapy, core buildups, additional crown, and alveoloplasties. The Plan denied your request. The Plan says diagnostic casts, endodontic therapy, core buildup, and alveoloplasty are not covered benefits. The Plan also says that benefits for crowns have been satisfied and the frequency limitation had 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, diagnostic casts, endodontic therapy, core buildup, including any pins when required, and alveoloplasty in conjunction with extraction are not among those covered under this benefit. The contract also clearly states that crowns are limited to one procedure per calendar year. The record shows that you received two crowns on November 5, 2019, one of which was covered by the Plan, and your crowns benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the diagnostic casts, endodontic therapy, three core buildups, including any pins when required, additional crown, and two alveoloplasties in conjunction with extractions provided from October 24, 2019 to November 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Aflibercept injection provided on June 19, 2018.
You asked the Plan to waive the coinsurance for the injection. You say that you were not notified there was a coinsurance. The Plan denied your request. The Plan says that cost-sharing is a contractual obligation of the plan and cannot be waived.
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 10% coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay a 10% coinsurance for the injection. The injection falls within the Medicare Part B Prescription Drugs 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 Aflibercept injection provided on June 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment - includes placement (D6057) and abutment supported porcelain fused to metal crown (D6059).
You asked the Plan to pre-approve the custom fabricated abutment - includes placement and abutment supported porcelain fused to metal crown. You say that you feel your dental benefit of $1,000 should be available according to the need to maintain your best dental health. The Plan denied your request. The Plan says these services are not covered under your 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 contract does have a $1,000 annual maximum benefit that can be used toward listed procedures that are covered. The requested items or services are not among those covered under this benefit and therefore, the $1,000 annual maximum benefit cannot be used. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment - includes placement (D6057) and abutment supported porcelain fused to metal crown (D6059).
Your complaint about the contradictions and misinformation given by the Plan 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from September 5, 2019 through September 7, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are on low income.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that youwere admitted on September 5, 2019 and discharged on September 7, 2019. You were asked to pay a $250 copayment per day from September 5, 2019 through September 6, 2019, days 1-2 of your inpatient hospital care. You were discharged on September 7, 2019 andthere was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-6 for in-network inpatient hospital care. 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 forinpatient hospital care from September 5, 2019 through September 7, 2019 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurological monitoring performed during multilevel cervical spinal surgery (95999) provided to the enrollee on February 12, 2019. You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Train of Four is considered a bundled procedure and payment for it is included in payment for the already approved neuromonitoring. Therefore, we decided that the Plan does not have to pay for intraoperative neurological monitoring performed during multilevel cervical spinal surgery (95999) provided to the enrollee on February 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (E1390) purchased on July 8, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an oxygen concentrator purchased on July 8, 2019. You are asked to pay 20% coinsurance for the DME. 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 oxygen concentrator (E1390) purchased on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic images (D0350 x 4) provided on November 2, 2019.
You asked the Plan to pay for the dental service. You say that you went to a different provider due to billing issues with the previous dental provider. You say that you want to make sure the provider is paid for the services that were rendered. You also say that the letter mentioned that the services may be duplicates. The Plan denied your request. The Plan says 2D oral or facial photographic images are not listed as a covered service.
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 2D oral or facial photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 2D oral or facial photographic images (D0350 x 4) provided on November 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide continued use of the CPAP and humidifier.
You asked the Plan to provide continued use of the CPAP and humidifier. You say that you have been unable to use the CPAP and humidifier because of medical conditions. The Plan denied your request. The Plan says you have not met criteria but they will allow additional time to submit another compliance report.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued use of the CPAP and humidifier have not been met. Therefore, we decided that the Plan does not have to provide continued use of the CPAP and humidifier.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on August 14, 2019.
You asked the Plan to pay for the drug test. You say that the service provided was medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 services at issue. 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 a drug test provided on August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee. You asked the Plan to pre-approve IRF care. You say that the enrollee can't be discharged without rehab. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 8, 2020 with a urinary tract infection and kidney failure from dehydration. She is now medically stable. There are no complex medical issues that require monitoring by inpatient physical medicine and rehabilitation or acute rehab nursing care. She may benefit from further therapy but does not require an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urinalysis and ECG provided by on October 15, 2019.
You asked the Plan to waive the copayment for the urinalysis and ECG. You say that you thought an annual physical was fully covered. The Plan denied your request. The Plan says the copayments 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 $10 copayment for each covered lab service and a $65 copayment for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay a total of $19.20 for the urinalysis and ECG. The urinalysis and ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 urinalysis and ECG provided by on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation care from September 21, 2019
through September 22, 2019.
You asked the Plan to waive the copayment for observation care. You say that you should not be responsible
for this charge because your inpatient. The Plan denied your request. The Plan says the claim was processed
accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received observation care from September 21, 2019 through September 22,
2019. You are asked to pay a $200 copayment for the observation care. 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 observation care from September 21, 2019 through September 22, 2019.