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

We decided that the Plan does not have to pre-approvea complete mandibular denture (D5120), and a complete maxillary denture (D5110).You asked the Plan to pre-approvethe dental items. You say that the enrollee advised that the original lower denture was done defectively. You say that the previous dentist put posts in, then took them out and was still unable to get the denture tofit. You also say that the enrollee has filed a complaint against the dentist.The Plan denied your request. The Plan says the frequency limit of once every 5 years 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 coverage and dentures are listed as a covered service, the frequency limit has been reached. The record shows that you last received dentures on October 19, 2017.Therefore, we decided that the Plan does not have to pre-approvea complete mandibular denture (D5120), and a complete maxillary denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from April 17,
2019 through April 22, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that this was due to an increase in
your medication. You say that this shouldn't be your responsibility. The Plan denied your request. The Plan
says the copayment 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 $150
copayment per day for days 1-5 for each inpatient hospital stay.
You have been asked to pay a $750 copayment for the inpatient stay. ($150/day x 5 days = $750). The inpatient
stay falls within the "Inpatient hospital 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 copayment
for the inpatient stay provided from April 17, 2019 through April 22, 2019.
Your complaint about the doctor's neglect is not a valid appeal for medical coverage. This part of your
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision
about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 16, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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 nurse practitioner services provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by the out of
network provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says there are multiple in-network providers within 30
miles of the member's residence that could have rendered 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 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 provided on July 18, 2019 by
the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 16, 2019.
You asked the Plan to waive the copayment for the laboratory services. You say that this was for your yearly checkup. You say that you have used this facility before with no copayment. The Plan denied your request. The Plan says the copayment 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 $40 copayment for laboratory services at an in-network outpatient hospital.
You have been asked to pay a $40 copayment for the laboratory services. The laboratory services fall 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 laboratory services provided on August 16, 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
acute-on-chronic respiratory failure in the setting of chronic obstructive pulmonary disease (COPD),
obstructive sleep apnea (OSA), obesity hypoventilation syndrome (OHS) and morbid obesity. At baseline, the
enrollee has a tracheotomy and home ventilator. The enrollee is currently tolerating her tracheotomy and
nightly ventilator. Given her medical co-morbidities, there is no expectation that the enrollee is to be
decannulated or free of using a ventilator. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 12, 2019 to October 31, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 12, 2019 to October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the cost share amount for the second stage implant surgery (D6011), and the therapeutic parenteral drugs (D9612) provided on July 10, 2019.
You asked the Plan to pay the cost share amount for the dental services. You say that you should not be liable for the cost share due to the fact that the services should be covered. The Plan denied your request. The Plan says the annual maximum 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 coverage, the Plan only covers up to the annual maximum of $2,250 for preventive comprehensive dental services.

Date of Service: 4/22/2019
Submitted Charge: $223
Savings: $58
Plan Paid: $165
Enrollee Liability: $0

Date of Service: 5/20/2019
Submitted Charge: $195
Savings: $75
Plan Paid: $120
Enrollee Liability: $0

Date of Service: 7/10/2019
Submitted Charge: $3,220
Savings: $1,020
Plan Paid: $1,795
Enrollee Liability: $405

Date of Service: 11/22/2019
Submitted Charge: $1,460
Savings: -
Plan Paid: $170
Enrollee Liability: 1,290

TOTAL Plan Paid:
$2,250

Therefore, we decided that the Plan does not have to pay the cost share amount for the second stage implant surgery (D6011), and the therapeutic parenteral drugs (D9612) provided on July 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that thePlan does not have to waive the copayment forinpatient hospital care provided from July 12, 2019 through July 16, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you had to be admitted to the"the clinic" because the staff at "the health center" did not solve your problem.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). Per your benefits in the 2019 EOC, you are responsible for $360 copayment each day for days 1 to 5 for Medicare-covered hospital care and $0 copayment for additional Medicare-covered days. You received inpatient hospital services for a total of 4 days. Hence, the assessed cost-share in the amount of $1440 applied correctly ($360 per day x 4 days = $1440 copayment). 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 inpatient hospital care provided from July 12, 2019 through July 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee's specialist agrees that an LTACH is the next step. You say that the enrollee keeps getting denied for acute rehab because he cannot do physical therapy right now.The Plan denied your request. The Plan says the requirements for coverage have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, andappropriate 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure in the setting of a newly diagnosed, unspecified, neuromuscular disorder. The enrollee was intubated/ventilated and eventually received a tracheotomy. The enrollee continues to be on a ventilator. Without a definitive diagnosis it is difficult to know if ventilator weaning and/or decannulation are possible. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381 x 3) provided on June 13, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the provider did not provide a current pocket depth chart, previous date of SRP, and the member is not having continuous regular periodontal maintenance, i.e. every 3 months as recommended by the provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the dental services. Our physician reviewer found due to the lack of the documentation of periodontal disease in this patient (pocket depth measurements, bleeding with probing, bone loss) it is my opinion that the criteria for coverage for the use of antimicrobials (D4381) around teeth #'s 3, 14 and 18 has not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth (D4381 x 3) provided on June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from August 5, 2019 through August 8, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that the hospital did nothing to treat you and you were transferred to another hospital.The Plan denied your request. The Plan says theclaim 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). You received inpatient hospital care from August 5, 2019 to August 8, 2019. A copayment of $265.00 per day was applied to two days of inpatient hospital care for a total copayment in the amount of $530.00 ($265.00 x 2). 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 provided from August 5, 2019 through August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay formeal replacement provided from July 9, 2019 through August 9, 2019.You asked the Plan to pay forthe meal replacement. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Meal replacement is not covered under Medicare or the Health Plan.Therefore, we decided that the Plan does not have to pay formeal replacement provided from July 9, 2019 through August 9, 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 you have similar issues with your feet as a
diabetic does. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided byan out-of-network providerfrom April 24, 2019 through April 30, 2019.You asked the Plan to waive the copayment forinpatient hospital care. 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). The out-of-network provider billed the inpatient room and board service in the amount of $17,280.00 and the allowed amount is $16,534.92. Per the EOC, members are responsible for a 40% coinsurance for an out-of-network hospital claim. The coinsurance should have been $6613.97 ($16,534.92 x 40%). However, you only needed to pay $6,463.22 in order to meet you combined out-of-pocket maximum of $10,000.00. The plan applied $6,463.22 as your coinsurance. 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 provided by an out-of-network provider from April 24, 2019 through April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic blood pressure monitor (A4670) and sales tax purchased from a non-contracted provider on September 2, 2019.
You asked the Plan to pay for the item. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis. Records show that you are not on home dialysis. Although a home blood pressure monitor may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item for your condition. The plan reviewed the Medicare website and this item is a non-covered item through Medicare. Therefore; as your plan is a Medicare Advantage plan, we have to follow Medicare guidelines. In addition; the provider is not a Medicare certified provider and the plan cannot pay a provider who is not eligible to participate in Medicare. Therefore, we decided that the Plan does not have to pay for automatic blood pressure monitor (A4670) and sales tax purchased from a non-contracted provider on September 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional non-emergent non-ambulance transportation.
You asked the Plan to provide non-emergent non-ambulance transportation. You say that you are requesting additional trips for medical visits. The Plan denied your request. The Plan says you exhausted 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 six (6) one-way 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 non-emergent non-ambulance transportation. The 7th trip and beyond is not a covered benefit. Your EOC clearly states, enrollees must pay $0 for six (6) trips, one-way trip or return trip, each year. Each one-way trip or return trip means one individual trip. Therefore, we decided that the Plan does not have to provide additional non-emergent non-ambulance transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on
October 4, 2019.
You asked the Plan to waive the copayment for the diagnostic mammogram. You say that this is a once a year
check for breast cancer. The Plan denied your request. The Plan says the copayment 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 $15
copayment for a diagnostic mammogram at an in-network outpatient hospital.
You have been asked to pay a $15 copayment for the mammogram. The mammogram falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you
have a personal history of breast cancer. 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
diagnostic mammogram provided on October 4, 2019.