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

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.You asked the Plan to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments. The Plan denied your request. The Plan says you do not meet the criteria established to receive the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020 and require intensive care coordination, and must be at high risk of hospitalizations or adverse health outcomes. You do not require intense care coordination, has no high risk for hospitalizations or high risk for adverse health outcomes.The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit yourhealth or general functioning.In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that the certification from your primary care physician dated March 30, 2020 documented that you have only one of the qualifying diagnoses under mentalconditions of mayor depression but you do not require intense care coordination, you have no high risk for hospitalizations or high risk for adverse health outcomes.Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses RT,LT (L1833x2) and suspension sleeves RT,LT (L2397x2) provided October 29, 2019.You asked the Plan to pay for the orthoses. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says The services are not supported in the medical records received.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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. The documentation in the case file doesnot support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay forknee orthoses RT,LT (L1833x2) and suspension sleeves RT,LT (L2397x2) provided October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on December 12, 2019.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that when you signed up forthis plan you were told that you had 2 cleanings per year.The Plan denied your request. The Plan says the benefits for these services have been satisfied and the frequency limitations have 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, exams and prophylaxis are each limited to one procedure per calendar year. The record shows that you received a periodic oral evaluation and prophylaxis on April 10, 2019 and your exams and prophylaxis benefits were then exhausted. Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on December 12, 2019.Your complaint about your dissatisfaction with 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on May 14, 2018.You asked the Plan to pay forthe ambulance services. You say that the claim was filed timely.The Plan denied your request. The Plan says the claim was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the ambulance services was not filed until November 11, 2019. This means that more than one calendar year fromthe date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forservices provided on May 14, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 1, 2019 by an out of network provide.You asked the Plan to pay forthe injections. You say that the injections were medically necessary.The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide 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 forthe medical services provided on October 1, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forscreening testing provided by provider on August 1, 2019.You asked the Plan to pay forscreening tests. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were performed for screening purposes which is not a Medicare benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, screening tests, were requested solely for screening purposes. Medicaredoes not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forscreening testing provided by provider on August 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve varicose vein services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve varicose vein services. You say that there is established care with this patient.The Plan denied your request. The Plan says there are in-network providers available for these services.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. Please contact the Plan for a list of in-network providers available for these services. 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 varicose vein services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the mammogram and the ultrasound provided on October 30, 2019.You asked the Plan to waive the copayments for mammogram and the ultrasound. You say that you were not informed that you would have to pay a copayment. You say that this is a large charge. 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 $150 copayment for outpatient x-rays taken at any other location and a $125 copayment for other diagnostic procedures and tests at any other location. For this date of service, you have been asked to pay the allowed amount of the claims because this amount is less than the $150 copayment for the mammogram and $125 for the ultrasound.You have been asked to pay a $109.42 copayment for the mammogram and a $57.33 copayment for the ultrasound. The mammogram and the ultrasound fall 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 copayments for the mammogram and the ultrasound on October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on December 3, 2019.You asked the Plan to pay more forthe problem focused limited oral evaluation and first intraoral periapical x-ray. You say that you do not have the funds to pay for these charges. You also say that these charges will cause hardship.The Plan denied your request. The Plan says you had exceeded your maximum benefit. The Plan also says that per your claim history, the Plan had issued a total of $1,000 toward your maximum 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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on December 3, 2019 and your annual maximum benefit was then exhausted.Therefore, we decided that the Plan does not have to pay more for the problem focused limited oral evaluation and first intraoral periapical x-ray provided on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) and supplies for the enrollee.You asked the Plan to pre-approvea CGM and supplies. The Plan denied your request. The Plan says that the enrollee does not meet criteria for these services.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met.We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) and supplies for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient diagnostic tests and does not
have to waive the copayment for a specialist visit provided on November 5, 2019.
You asked the Plan to waive the coinsurance for outpatient diagnostic tests and to waive the copayment for a
specialist visit. You say that 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 15%
coinsurance for outpatient diagnostic tests. Your contract with the Plan also clearly says that you must pay a
$25 copayment for a specialist visit.
You received outpatient diagnostic tests on November 5, 2019. The total allowed amount is $1,956.73 and 15%
of that is $293.51.
You received specialist services on November 5, 2019. Therefore, you are responsible to pay the allowed
amount of $22.31.
The total amount you owe is: $315.83.
You have been asked to pay the total amount of $315.83 for outpatient diagnostic tests and a specialist visit.
Outpatient diagnostic tests fall within the outpatient diagnostic tests and therapeutic services and supplies
benefit category. A specialist visit falls within the physician/practitioner services, including doctor's office
visits 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 outpatient diagnostic tests and
does not have to waive the copayment for a specialist visit provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your foot disability makes it difficult to walk in regular shoes. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 25, 2019 by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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. 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 forthe medical services provided on September 25, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 12, 2019.You asked the Plan to pay for the services. You say that you could not get an appointment with your PCP.The Plan denied your request. The Plan says the services are available in-network.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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on November 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers
available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider
on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided to the enrollee by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that the requested treatment is medically necessary due to the enrollee's diagnosis.The Plan denied your request. The Plan says the enrollee's needs can be met within the plan network.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided to the enrollee 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 eyeglasses provided on November 21, 2019.You asked the Plan to pay for the eyeglasses. You say that you fell and broke your eyeglasses and needed to purchase another pair of eyeglasses. The Plan denied your request. The Plan says replacement eyeglasses due to loss, damage,style or stolen (glasses or contact lenses) are not covered.Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. The file shows that you needed replacement eyeglasses because your original eyeglasses were damaged when you fell and broke them. The Plan does not cover replacement eyeglasses. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on November 21, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for an ultrasound (76882) provided on December 9, 2019.You asked the Plan to waive the copayment for the ultrasound. You say that you would like reconsideration because there is no charge or co-pay specified in the EOC for outpatient ultrasound exams.The Plan denied your request. The Plan says that according to your health plan benefit, you are covered for ultrasound services which are categorized under X-ray services as it is a type of X-ray.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 does not say in clear and accurate terms how much you should expect to pay for ultrasound examinations. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $15 copayment for ultrasound examinations. The Plan contract does not clearly say how much enrollees must pay for ultrasound examinations. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the copayment for an ultrasound (76882) provided on December 9, 2019.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 periodontal maintenance provided by an OON provider
on December 3, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that when you signed up for this plan you
were told that your dentist and periodontist would be covered 100%. The Plan denied your request. The Plan
says you received services from an OON provider, and the provider claim was processed with the correct
member responsibility.
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, when using an out-of-network dentist,
you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided
that the Plan does not have to pay for the periodontal maintenance provided by an OON provider on December
3, 2019.
Your complaint about being disappointed and aggravated with 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.