Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on August 15, 2019.
You asked the Plan to waive the coinsurance for the Euflexxa injection. You say that you refuse to pay for services that did not help. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs. You have been asked to pay $147.76, which is 20% of the allowed amount for the Euflexxa injection. The allowed amount is $738.82 (20% x $738.82 = $147.76). The Euflexxa injection 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 when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on August 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), an additional periapical
x-ray (D0230), and bitewings (D0274) provided on December 10, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that your crown is causing you a lot of pain. You say
that it is oversized and rubbing on your bottom teeth. You say that you cannot afford to pay for the x-rays and
the crown. The Plan denied your request. The Plan says the provider in this case is not a network provider. The
Plan also says dental services that you receive out of network 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 dental services that you received
are not covered when you receive them out of network. The Evidence of Coverage clearly states that care
rendered by a provider that is not part of our supplemental dental network is not covered. Therefore, we
decided that the Plan does not have to pay for the initial periapical x-ray (D0220), an additional periapical x-ray
(D0230), and bitewings (D0274) provided on December 10, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided from July 30, 2018 through August 10, 2018.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that this was a continuous stay. You say that you should only be charged for the first five days. 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 $300 copayment per day for days 1-5 and a $0 copayment per day for additional days for in-network, Medicare-covered inpatient hospital stays. Cost-sharing (copay and coinsurance) applies on the date of admission each time you are admitted or transferred to a specific facility type, including Inpatient Rehabilitation facilities, Inpatient Acute Care facilities, Inpatient Long Term Acute Care hospitals and Inpatient Psychiatric facilities. You have been asked to pay a $1,500 copayment for the inpatient rehabilitation stay. ($300/day x first 5 days = $1,500). The inpatient rehabilitation stay falls within the "Inpatient hospital care" benefit category. A transfer to a different facility is considered a new admission. 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 rehabilitation stay provided from July 30, 2018 through August 10, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from January 16, 2018 to January 18, 2018.
You asked the Plan to pay for inpatient care. You say that this was a corrected claim. The Plan denied your request. The Plan says this claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for inpatient care was not filed until May 20, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from January 16, 2018 to January 18, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided tothe enrollee on April 3, 2019.You asked the Plan to pay forhome health services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the revenue codes and revenue descriptions were not submitted correctly per Medicare guidelines.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee on April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea mattress overlay.You asked the Plan to pre-approvea mattress overlay. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not medically necessary.The Plan follows Medicare rules. Medicare rules say that mattress overlays are only covered for certain indications.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 mattress overlay. Our reviewer says that the documentation does not support that the requested mattress overlay is medically reasonable or necessary. Our physician reviewer found the documentation shows that you had pain in both arms and chronic shoulder pain. Your spine, neurological, and extremity exam were within normal limits. You do not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of a mattress overlay per the LCD. You do not have complete immobility, limited mobility, or evidence of pressure ulcers on the trunk or pelvis per the submitted records. Therefore, you do not meet criteria for the requested item. 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 mattress overlay have not been met. Therefore, we decided that the Plan does not have to pre-approvea mattress overlay.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service, the enrollee lost her balance and fell down. The enrollee was uninjured in the fall and you called 911 to help pick the enrollee up. The fire department came and picked up the enrollee while also calling for an ambulance. You say that you did not request an ambulance and the enrollee was not treated or transported anywhere. You say you would like to dispute the charges for the ambulance response.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 August 20, 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 forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 2, 2019.You asked the Plan to pay for the physician's services. You say that you were not told this provider was out-of-network until after the service was performed. 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 casesinvolving 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 Plandid not pre-approve the physician's services.We found no exception that would require the Plan topay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin-based composite, first intraoral periapical x-ray, and problem focused limited oral evaluation provided on December 13, 2019.You asked the Plan to pay forthe resin-based composite, first intraoral periapical x-ray, and problem focused limited oral evaluation. You say that this provider's receptionist told you that the office visit and x-rays would be paid in full, and the filling would be covered at80%.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 contract clearly states that you are reimbursed in full for 2 routine preventive dental visits every year. The requested items or services are not considered routine preventive services and are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe resin-based composite, first intraoral periapical x-ray, and problem focused limited oral evaluationprovided on December 13, 2019.Your complaint about being misled by the provider 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 the typhoid and yellow fever vaccines provided on December 9, 2019.You asked the Plan to pay for the vaccines. You say that these should be covered as they were recommended by your doctor as well as the CDC.The Plan denied your request. The Plan says Medicare Part B does not cover these vaccines. Reimbursement can be requested from your Part D plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccines.Therefore, we decided that the Plan does not have to pay for the typhoid and yellow fever vaccines provided on December 9, 2019.Benefits for the vaccines 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the copayment for the eye exam provided on April 30, 2019.You asked the Plan to waive the copayment for the eye exam. You say that you were told there was no copay for this exam.The Plan denied your request. The Plan says that that there is a $35 copay for medical eye exams.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided their 2019 Evidence of Coverage. Without this document our plan is unable to substantiate the copay being charged for this service.Therefore, we decided that the Plan has to waive the copayment for the eye exam provided on April 30, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran observation stay provided from October 14, 2019 to October 15, 2019.You asked the Plan to waive the copayment foran observation stay. You say that you were not told that you were being admitted under observation.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 $350 copayment for observation stays.The medical records show that you had an observation stay from October 14, 2019 to October 15, 2019. Therefore, you are responsible to pay the $350 copayment.  You have been asked to pay a $350 copayment for an observation stay. An observation stay falls 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 foran observation stay provided from October 14, 2019 to October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight hours per day, seven days a week, totaling 56 hours per week of personal care services.You asked the Plan to pre-approve additional personal care services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 additional personal care services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found per the personal care assistant nursing assessment tool, you reported back and leg pain and unsteady gait. You were independent with feeding, positioning and toileting. You required limited assist with bathing. You required extensive assist with dressing. The records do substantiate your functional status and the need for personal care assistant services. However, the approved 22 hours should be sufficient to meet your care needs. The requested additional 34 hours are not medically necessary or reasonable to treat your diagnosis, condition, and/or symptoms.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional personal care services have not been met.Therefore, we decided that the Plan does not have to pre-approve eight hours per day, seven days a week, totaling 56 hours per week of personal care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two localized deliveries of antimicrobial agents provided on December18, 2019.You asked the Plan to pay for the two localized deliveries of antimicrobial agents. You say that you must see the dentist often to control the loss of your teeth. You also say that you pay extra for dental and vision services.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 two localized deliveries of antimicrobial agents provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on September 18, 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 services are not covered.The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS.We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. 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 assistant surgeon services rendered on September 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physical therapy and occupational therapy services provided from August 1, 2019 to October 31, 2019.You asked the Plan to pay forthe physical therapy and occupational therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says prior authorization was not obtained before receiving these services.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe physical therapy and occupational therapy services provided from August 1, 2019 to October 31, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for outpatient mental health care provided on February 6, 2020.You asked the Plan to waive this copayment. You say that you do not think you should be responsible for this copayment.The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by the provider and the Plan contract agreement.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 $40 copayment for outpatient mental health care. 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 $40 copayment charged for outpatient mental health care provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share amounts for the periodic oral
evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0272) provided on November 21, 2019.
You asked the Plan to waive the out of network cost share amounts for the dental services. You say that when
you called the plan to add the Dental Rider, you were advised that cleanings, exams and bitewings were
covered at 100% with in network and out of network dentists. You say that you called the plan after receiving
the bill. You also say that the initial plan representative that you had spoken to, gave you incorrect information.
The Plan denied your request. The Plan says the out of network cost sharing amounts were applied correctly to
the services that you received.
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,
dental services that you receive out of network, you are responsible for the difference between what the
provider billed and the allowed amount. This is a contractual obligation you agreed to when you enrolled in the
Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the out of network cost
share amounts for the periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0272)
provided on November 21, 2019.