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

We decided that the Plan does not have to pay for two (2) airline tickets purchased on August 1, 2019.You asked the Plan to pay for the airline tickets. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says this service is not covered by Medicare.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 airline tickets have not been met. This service is not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay fortwo (2) airline tickets purchased on August 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than $75 for eyewear provided on November 1, 2019.
You asked the Plan to pay more than $75 for the eyewear. The Plan denied your request. The Plan says that the Plan processed the claim correctly based on the enrollee's plan benefits having a maximum of $75 per every two (2) calendar years.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and 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 the Plan processed the claim with the correct eyewear benefit maximum of $75. Therefore, we decided that the Plan does not have to pay for the eyewear provided on November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe pacemaker check provided on August 21, 2019.You asked the Plan to waive the copayment forthe pacemaker check. You say that you do not have the money to pay for this. You say you have never had to pay for this service before. The Plandenied 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 $10 copayment for each covered visit or consultation in an outpatient location with your PCP or other primary care physician. You have been asked to pay a $10 copayment for the pacemaker check. The pacemaker check 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 copayment forthe pacemaker check provided on August 21, 2019.Our decision is only about the August 21, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported crown (D6066), re-cement or re-bond crown (D2920), prophylaxis (D1110), periodic oral evaluation (D0120), and bitewings (D0272) provided from May 20, 2019 to November 7, 2019.
You asked the Plan to pay for the implant supported crown, re-cement or re-bond crown, prophylaxis, periodic oral evaluation, and bitewings. You say that you were enrolled in the optional supplemental dental package #3 at the time of these services and you are being denied your benefits. The Plan denied your request. The Plan says implant supported crown, re-cement or re-bond crown, and bitewings are not covered by the Plan. The Plan says that the maximum allowed for the prophylaxis and periodic oral evaluation had been met.
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, implant supported crown, re-cement or re-bond crown, and bitewings are not covered under this benefit. The contract also clearly states that you are limited to 1 oral exam(s) and 1 cleaning(s) every year. The record shows that you received a prophylaxis and periodic oral evaluation on May 25, 2019 and your oral exam and cleaning benefits were then exhausted. The record also shows that you did not elect to purchase an optional supplemental benefit. Therefore, we decided that the Plan does not have to pay for the implant supported crown (D6066), re-cement or re-bond crown (D2920), prophylaxis (D1110), periodic oral evaluation (D0120), and bitewings (D0272) provided from May 20, 2019 to November 7, 2019.
Your complaint about being treated unfairly 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear provided on December 17, 2019.
You asked the Plan to pay for the eyewear. You say that you feel you are entitled to your benefits. The Plan
denied your request. The Plan says you exhausted your benefit allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and 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. You exhausted your benefit allowance, because you used the
eyewear benefit of $50 on January 3, 2019. Therefore, we decided that the Plan does not have to pay for
eyewear provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheter and lubricant provided on January 27, 2020.
You asked the Plan to waive the coinsurance for these items. You say that you cannot afford to pay for these items. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for prosthetic devices and related supplies. You have been asked to pay a 20% coinsurance for these items. These items fall within the prosthetic devices and related 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 coinsurance for the catheter and lubricant provided on January 27, 2020.
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 forthe ambulance services. You say that you were at the hair salon when you fell and could not get up by yourself. An ambulance was called and the responders examined you to see if you were hurt anywhere. You say the EMTs then asked you if you wanted to go to the hospital and you declined.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 December 6, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from March 5, 2019 to March 26, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The claims were not billed with a valid TOB code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered to the enrollee from March 5, 2019 to March 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean upper and lower partial denture.You asked the Plan to pre-approvethe dental services. You say that you had surgery. You say that the facility lost the bag with your belongings, including your dentures. You also say that since then you havenot been able to eat and have had trouble chewing.The Plan denied your request. The Plan says 1 set of dentures is covered every 5 years. The Plan also says that the denture benefit 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 coverageand dentures are a covered service, the benefit limit for dentures has been exhausted. The record shows that you last received an upper and lower partial denture on March 24, 2016.Therefore, we decided that the Plan does not have to pre-approvean upper and lower partial denture
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SoClean CPAP cleaner and sanitizer device.You asked the Plan to pre-approve a SoClean CPAP cleaner and sanitizer device. You say that despite cleaning your CPAP with soap and water the equipment is not sanitized.The Plan denied your request. The Plan says the machine is hygienic and not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.The owner is expected to do routine maintenance. Therefore, we decided that the Plan does not have to pre-approve a SoClean CPAP cleaner and sanitizer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the rollator purchased on October 21, 2019 and the SaeboStep purchased on November 20, 2019.
You asked the Plan to reimburse you for the rollator and the SaeboStep. You say that these items were needed but were not available locally. The Plan denied your request. The Plan says the items at issue in this appeal were purchased from providers not certified by Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the different providers. This provider has opted out of the Medicare program. The file shows that the two providers entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the rollator purchased on October 21, 2019 and the SaeboStep purchased on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you fora CPAP battery backup purchased from Amazon.com on October 9, 2019.You asked the Plan to reimburse you fora CPAP battery backup. You say that there are power outages in your location and you were concerned about using your CPAP machine.The Plan denied your request. The Plan says a CPAP battery backup is a convenience item and not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Also, payment cannot be made for items purchased on Amazon.combecause Amazon.comis not a medical provider and is not enrolled in Medicare.Therefore, we decided that the Plan does not have to reimburse you fora CPAP battery backup purchased from Amazon.com on October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Aminolevulinic Acid Hcl provided on January 15, 2020.You asked the Plan to waive the coinsurance forthis drug. You say that you were informed there would be no copayment balance.The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for this drug. This drug 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe Aminolevulinic Acid Hcl provided on January 15, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial lower denture (D5214).You asked the Plan to pre-approvea partial lower denture. You say that you need the dentures because you only have a few bottom teeth left and is mostly chewing with your gums and it's causing you to get indigestion and affecting your health.The Plan denied your request. The Plan says the requested service is not covered under the plan 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 thePlan 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-approvea partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 28, 2019 to November 8, 2019 to the enrollee by an out of network (OON) 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 an out-of-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 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 28, 2019 to November 8, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system and supplies (K0553, K0554).
You asked the Plan to pre-approve a CGM system and supplies. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that CGM devices are covered when specific criteria is met. 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 a CGM system and supplies. Our reviewer says that the items are not medically necessary. Our physician reviewer found you are noted to be a type II diabetic, who takes oral medication to treat your diabetes. How often you test your blood glucose is not documented. There is no evidence that you use the results of blood glucose testing to self-adjust the dose of self-administered insulin multiple times a day. As such, the documentation does not show that the requested CGM is currently medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CGM system and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system and supplies (K0553, K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99354 provided on July 3, 2019 and September 2, 2019.
You asked the Plan to pay for CPT code 99354. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 99354.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99354 is Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour. We find that CPT code 99354 is not supported in the medical record. Specifically, there is no documentation of the total duration of time spent with the enrollee. Based on this information, we decided that Medicare rules for coverage of CPT code 99354 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99354 provided on July 3, 2019 and September 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forspecialist services provided in an outpatient hospital facility on January 15, 2020.You asked the Plan to waive the copayment forspecialist services. 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 a $50 copayment for each specialist visit provided in an outpatient hospital facility. You have been asked to pay a $50 copayment for specialist services. Specialist services fall within the outpatient hospital 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 copayment forspecialist services provided in an outpatient hospital facility on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 21, 2019 by an out of network (OON) provider.You asked the Plan to pay forclinic services. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial ofpayment for these services is correct, because this provider is out-of-network with the Plan and the enrollee could have received service 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 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, wedecided that the Plan does not have to pay forthe medical services provided on November 21, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services provided from November 5, 2019 to November 25, 2019.You asked the Plan to waive the copayments for cardiac rehabilitation services. You say that you would like to pay $40 per each visit.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 cardiac rehabilitation services. You received cardiac rehabilitation services from November 5, 2019 to November 25, 2019 for a total of 5 visits. Therefore, the total amount you owe is: $50 (copayment) x 5 (rehabilitation services) = $250. You have been asked to pay the total copayment amount of $250 for cardiac rehabilitation services. Cardiac rehabilitation services fall within the cardiac 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 cardiac rehabilitation services provided from November 5, 2019 to November 25, 2019.