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

We decided that the Plan does not have to waive the copayments fora specialist visit and an X-ray provided on October 21, 2019.You asked the Plan to waive the copayments fora specialist visit and an X-ray. You say that you disagree with the charges because the doctor could not treat you.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 $40 copayment per specialist visit. Your contract with the Plan also clearly says that youmust pay a $40 copayment for each basic imaging service.You received a specialist visit on October 21, 2019. Therefore, you are responsible to pay the $40 copayment. You received an X-ray on October 21, 2019. Therefore, you are responsible to pay the allowed amount of $31.66, which is less than the $40 copayment. The total amount you owe is: $71.66. You have been asked to pay the total copayment amount of $71.66 for a specialist visit and an X-ray. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. 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 copayments fora specialist visit and an X-ray provided on October 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from September 18, 2019 to October 8, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you disagree with the charges because the Plan required it but the services only made your condition more painful. 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 $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from September 18, 2019 to October 8, 2019 for a total of 6 visits. Therefore, you are responsible to pay the total amount of $202.02, which is less than the total copayment amount. You have been asked to pay the total amount of $202.02 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided, from September 18, 2019 to October 8, 2019.
We note your complaint that the Plan required the outpatient rehabilitation services in order to approve a surgical procedure. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that the color does not match your other teeth. You also say that the dentures were forming mildew inside. The Plan denied your request. The Plan says this service is allowed one time in 5 years. The Plan also says that you have already had this service within the past five years and have reached the limit for this 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, dentures (either D5110, D5211 or D5213) are limited to one per 5 calendar years. The record shows that you received a partial denture on November 1, 2018 and your dentures benefit (of codes D5110, D5211, or D5213) is now exhausted. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (82378, 82750, 84156, 85025, 96416, J2997, Q0162, and 36593) provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for out-of-network services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 medical services (82378, 82750, 84156, 85025, 96416, J2997, Q0162, and 36593) provided on October 22, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic procedure and 4 alveoloplasties.
You asked the Plan to pre-approve the diagnostic procedure and 4 alveoloplasties. You say that you are on blood thinners and cannot take any pain medications. You also say that you would like these procedures done in a hospital setting because it is safer for you and medically necessary. The Plan denied your request. The Plan says these 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 pre-approve a diagnostic procedure and 4 alveoloplasties.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 3, 2019 and billed under code G0483.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the medical records provided do not support the services billed.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 3, 2019 and billed under code G0483.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the root canal (D3330) and the resin based composite for 1 surface (D2391) provided on October 24, 2019.
You asked the Plan to pay the full amount for the dental services. You say that the provider advised they verified coverage and the dental plan limit was $1,000. You say that the provider was advised by the Plan that the entire negotiated amount of $1,432 would be covered. The Plan denied your request. The Plan says the annual maximum of $1,000 for dental services has been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the annual maximum of $1,000 has been reached in the processing of the claim. Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility.
Date of Service
CPT Code
Billed Amount
Allowed Amount
Plan Paid
Cost Share
10/21/2019
D0150
$99
$67
$67
-
10/24/2019
D0140
$85
$70
$70
-
10/24/2019
D0220
$34
$19
$19
-
10/24/2019
D0364
$150
$150
$150
-
10/24/2019
D3330
$1,163
$694
$694
$41
10/24/2019
D2391
$187
$0
$0
$187
TOTAL:
$1,000
$228
Therefore, we decided that the Plan does not have to pay the full amount for the root canal (D3330) and the resin based composite for 1 surface (D2391) provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fabrication of an oral appliance.
You asked the Plan to pre-approve the durable medical equipment (DME). You say that you received approval for the service. The Plan denied your request. The Plan says the service can be provided 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 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. You are not a network provider with the Plan. The Plan has confirmed there are 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 the fabrication of an oral appliance.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 20, 2019
through October 25, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the medical records provided indicate that the admitting physician expected the enrollee's
admission to span two midnights. The enrollee had specialty consultations, imaging, respiratory treatments, and
intravenous medications. His respiratory status was closely monitored. Inpatient care services were appropriate
and supported by the documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from October 20, 2019 through October 25, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Inogen portable oxygen concentrator.You asked the Plan to pre-approvean Inogen portable oxygen concentrator. You say that theInogen portable oxygen concentrator is lighter than the one you have and you would be able to get out more comfortably.The Plan denied your request. The Plan says the Inogenbrand is not covered by the Plan.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.Medicare covers home oxygen equipment.The file shows that you have an Eclipse 5 portable oxygen concentrator. TheEclipse 5 portable oxygen concentrator serves the same purpose as an Inogen portable oxygen concentrator.The documentation does not show that your current concentrator, provided on October 23, 2019, is not meeting your medical needs. The Plan does not cover the Inogen brand. Therefore, we decided that the Plan does not have to pre-approvean Inogen portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for vision services provided on November 15, 2019 and December 9, 2019.
You asked the Plan to waive the copayments for vision services. You say that these were follow-up visits and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for vision care. You received vision services on November 15, 2019 and December 9, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $50 copayment per each visit. The total amount you owe is: $100.00. You have been asked to pay the total copayment amount of $100.00 for vision services. Vision services fall within the vision care 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 vision services provided on November 15, 2019 and December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a gangrenous gallbladder. Following initial stabilization, the enrollee eventually had her gallbladder removed. She is currently being evaluated for a post-surgical fluid collection. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe nuclear medicine test provided on July 18, 2019.You asked the Plan to waive the copayment forthe nuclear medicine test. You say that you were never in a hospital for the test. You say you were never admitted. 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 $250 copayment for nuclear medicine services at an in-network outpatient hospital. You have been asked to pay a $250 copayment for the nuclear medicine test. The nuclear medicine test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital.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 doesnot have to waive the copayment forthe nuclear medicine test provided on July 18, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and resin-based composite.
You asked the Plan to pre-approve the consultation and resin-based composite. You say that you are trying to find a dentist that has the right resin for your mouth and a lot of the providers will not tell you what they use. The Plan denied your request. The Plan says the provider you are requesting to render these services is not a participating provider. The Plan also says that there is no benefit for dental services performed by an out-of-network provider. You also say that this is the only provider you have found that uses the correct resin material.
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 out-of-network. Therefore, we decided that the Plan does not have to pre-approve a consultation and resin-based composite.
Your complaint about the Plan not working with you 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.
You asked the Plan to pay for incontinence supplies. You say that you received a denial notice for the purchased supplies. You say that your primary care doctor requested the supplies for you. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had gotten dizzy when out with your daughter and a passerby called for an ambulance without your knowledge. When the ambulance arrived they checked your blood pressure and determined that you were dehydrated. You say they deemed it unnecessary for you to go to the hospital and you agreed. You said that you were trying to avoid a large bill and that the response services should be covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 9, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature or electronic upgrades.You asked the Plan to pre-approve the power seat elevation feature and electronic upgrades. You say that with the expandable harness the enrollee can operate the seat functions with one hand and the seat elevation feature will allow transfers independently.The Plan denied your request. The Plan says power seat elevation features are not covered and there is no medical need to control the power options through the joystick.The Plan must follow Medicare rules. The rules say that for equipment to be covered, itmust primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The seat elevation featureat issue in this appeal does not serve a purpose that is primarily medical in natureand therefore is not covered by Medicare. Documentation shows limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.Therefore, we decided that the Plan does not have to pre-approvethe power seat elevation feature or electronic upgrades.