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 transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services.
You asked the Plan to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services. The Plan denied your request. The Plan says for an enrollee to be a candidate for these benefits he/she needs to have one or more of the eligible chronic conditions documented in the Evidence of Coverage for 2020 and require intensive care coordination, and must be at high risk of hospitalizations or adverse health outcomes. The enrollee does not meet any of these criteria and for this reason the benefits were denied.
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 your health 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 you do not have one or more of the qualifying diagnoses, you do not require intense care coordination, and you have no high risk for hospitalizations or high risk for adverse health outcomes. Based on this information, we decided that the Plan's rules for coverage of a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services have not been met. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions and four 2D oral/facial photographic images provided on January 22, 2020.You asked the Plan to pay forthe oral hygiene instructions and 2D oral/facial photographic images. You say that you were given x-rays and panoramic x-rays, but no mention was made that an additional x-ray was needed. You also say that you were not told that there would be an added cost over what the Plan would cover.The Plan denied your request. The Plan says these services are not covered.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 pay for the oral hygiene instructions and four 2D oral/facial photographic images provided on January 22, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAcitretin for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is prescribed at low dose to prevent formation of cutaneous squamous cell carcinoma.The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveAcitretin for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 3, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford to pay. 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 $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 for the ambulance transport provided on January 3, 2020.
Appeal type: Outpatient Therapies
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 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided byon December 13, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the Plan should pay this claim.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visitis not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to payforthe lumbar-sacral orthosis provided on December 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 22, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you had to be transferred
to a different hospital after your surgery. You say you should not be responsible for the copayment. 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 $125
copayment for Medicare-covered ambulance services per day.
You have been asked to pay a $125 copayment for the ambulance transport. The ambulance transport falls
within the "Ambulance 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 for
the ambulance transport provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oral appliance.You asked the Plan to pre-approvean oral appliance (E0486). You say that theenrollee meets criteria for an oral appliance.The Plan denied your request. The Plan says the records do not show the enrollee is intolerant to a PAP device. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The sleep study or physician donot show the use of a PAP device is contraindicated. Based on this information, we decided that Medicare rules for coverage of an oral appliance have not been met.Therefore, we decided that the Plan does not have to pre-approvean oral appliance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on January 23, 2020.
You asked the Plan to pay for the resin-based composite. You say that you feel this was an emergency procedure and should be covered under your plan. The Plan denied your request. The Plan says this service is not covered.
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 pay for the resin-based composite provided on January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for hospitaloutpatient services provided on February 12, 2020.You asked the Plan to pay for the hospital outpatient services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care,dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 hospital outpatient services provided on February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided October 7, 2019.
You asked the Plan to pay for the PET scan. You say that the service was medically necessary. The Plan denied your request. The Plan says a correct diagnosis code was not billed for the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 78815 is not supported in the medical record. Specifically, C51.9 is not listed as a valid diagnosis code for this CPT code. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that you need assistance getting out of bed. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral medications provided during your outpatient hospital stay from December 10, 2019 to December 11, 2019.You asked the Plan to reimburse you for the oral medications. You say that you received a bill from the hospital for $80.50. You say that you called the hospital to inquire about this bill and were advised it had to be paid but you could appeal it.The Plan denied your request. The Plan says the oral medications that you received are considered "self-administered". The Plan says that self-administered drugs are not covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to reimburse you for the oral medications provided during your outpatient hospital stay from December 10, 2019 to December 11, 2019.Benefits for the oral medications may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the CT scans and the MRIs provided from
January 12, 2020 to February 4, 2020.
You asked the Plan to waive the copayments for the CT scans and the MRIs . You say that you should not be
charged individually for each service since they are all related to your stroke. 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 $295
copayment for CT scans and a $295 copayment for diagnostic radiology other than CT scans.
You have been asked to pay a total of $885 for the CT scans and the MRIs. The CT scans and the MRIs fall
within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service Service Allowed Amount Copayment Member Liability
January 12, 2020 MRI $686.76 $295 $295
January 21, 2020 CT scan $520.20 $295 $295
February 4, 2020 CT scan $215.85 $295 $215.85
February 4, 2020 MRI $714.20 $295 $79.15
Total $885
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 CT scans and the MRIs provided from January 12,
2020 to February 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior nasal nerve cryoablation (Clarifix procedure).
You asked the Plan to pre-approve Clarifix procedure. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because medical studies have not proven that Clarifix is helpful for the enrollee's condition.
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 pre-approve Clarifix procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee suffers from rhinitis. Clarifix has been Food and Drug Administration (FDA) approved to improve rhinitis in patients. However, the evidence supporting use of the device is sponsored by the makers of the device. In a systematic review, it states that although cryotherapy appears to be safe and efficacious, past investigations with low-quality evidence make strong, evidence-based recommendations difficult. Use of Clarifix should be denied because medical studies have not proven that this procedure is helpful for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Clarifix procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve posterior nasal nerve cryoablation (Clarifix procedure).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on October 28, 2019.
You asked the Plan to pay for the retreatment of previous root canal therapy. You say that after this provider performed the examination, they informed you that they did not participate in Medicare Advantage. You also say that you assumed you had partial coverage because one of the providers of this office was listed as a contracted provider. The Plan denied your request. The Plan says the provider who rendered the service had opted out of Medicare and does not participate with your plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a non-participating provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the retreatment of previous root canal therapy provided on October 28, 2019.
Your complaint about being misled by the Plan's directory 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 the periapical x-ray (D0220), the consultation including oral evaluation (D9310), the cone beam CT (computed tomography) image capture with limited field of view (D0380), and the pulp vitality test (D0460) provided on December 16, 2019.
You asked the Plan to pay for the dental services. You say that the provider did not inform you that he was not contracted with your Plan. The Plan denied your request. The Plan says the provider in this case is not a participating provider. The Plan also says that dental services must be provided by a participating provider in order to be covered.
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, dental services that provided out of network are not covered. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220), the consultation including oral evaluation (D9310), the cone beam CT (computed tomography) image capture with limited field of view (D0380), and the pulp vitality test (D0460) provided on December 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance services provided on January 24, 2020.You asked the Plan to waive the copayment for non-emergency ambulance services. You say that you were under the impression the services would be covered.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received non-emergency ambulance services provided on January 24, 2020. You are asked to pay a $265 copayment for the ambulance services. 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 non-emergency ambulance services provided on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions provided on November 13, 2019.
You asked the Plan to pay for the extractions and alveoloplasties. You say that you feel this should be submitted as a special medical service because of the provider you were referred by. You also say that these services needed to be rendered before open heart surgery, due to risk of infection. The Plan denied your request. The Plan says your $500 annual maximum had 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 offers a $500 annual dental benefit maximum. The record shows that you met the annual maximum benefit on November 13, 2019, while processing this claim, and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the extractions provided on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that the member was in a nursing home. You say that it is the nursing home's responsibility to obtain prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 lab tests provided on December 20, 2019 by an out of network (OON) provider.