Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seating system or cushions.
You asked the Plan to pre-approve a power seating system, tilt only (E1002), custom wheelchair back cushion (E2617) and custom seat cushion (E2609). You say that the enrollee needs a manual wheelchair and accessories. The Plan denied your request. The Plan says power tilt is only covered for a power wheelchair and cushions on patient-owned wheelchairs are not covered.
The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. We looked at the file and Medicare rules. Power tilt is not covered for manual wheelchairs. The diagnosis codes in the case file do not qualify for custom cushions. Based on this information, we decided that Medicare rules for coverage of a power seating system, tilt only (E1002) custom wheelchair back cushion (E2617), and custom seat cushion (E2609) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seating system or cushions.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from November 1, 2020, to November 11, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you were kept in the facility in order to receive antibiotics which was required by the Plan. 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 $0 copayment for days 1-20, and a $178 copayment for days 21-100 for SNF care.
You had a SNF stay from November 1, 2020, to November 11, 2020. The record shows that you had a previous SNF stay for a total of 14 days. Therefore, you are not being asked to pay a copayment for days 15-20 (November 1, 2020, to November 6, 2020). You are responsible to pay a $178 copayment for days 21-25 (November 7, 2020, to November 11, 2020). The total amount you owe is: $178 (copayment) x 5 (SNF days) = $890. You have been asked to pay the total copayment amount of $890 for a SNF stay. A SNF stay falls within the SNF 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 a SNF stay provided from November 1, 2020, to November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on February 9, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you would like this claim to be reconsidered. 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 comprehensive periodontal evaluation (D0180) provided on February 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0428) received December 12, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you were transferred to another facility so you should not have to pay anything. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 for Ambulance Services.
You have been asked to pay a $261.30 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0425, A0428) received December 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), and the prophylaxis - adult (D1110) received March 9, 2021 from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that you were not informed by the provider that they were not in network. The Plan denied your request. The Plan says there is no coverage for services received out-of-network.
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 when they are performed by an out-of-network dental provider.
Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), and the prophylaxis - adult (D1110) received March 9, 2021 from the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure provided on January 28, 2021.
You asked the Plan to pay for the preventive procedure. You say that prior to receiving the procedure you were advised that anesthesia was covered at 100%. 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 preventive procedure provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra wide heavy-duty hospital bed (E0303).
You asked the Plan to pre-approve an extra wide heavy-duty hospital bed. You say that the item is medically necessary. The Plan denied your request. The Plan says you do not meet the weight requirements for the equipment.
The Plan must follow Medicare rules. The rules say that a hospital bed may be considered medically necessary when at least one of the following criteria is met: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or 3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or 4. The patient requires traction equipment, which can only be attached to a hospital bed, and the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a hospital bed have not been met. Specifically, you do not meet the weight requirement for this item. Therefore, we decided that the Plan does not have to pre-approve an extra wide heavy-duty hospital bed (E0303).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0426, A0425) received December 31, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you needed to be transferred to another facility. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $175 copayment for Ambulance Services. You have been asked to pay a $175 copayment for the ambulance transportation. The ambulance transportation 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 transportation (A0426, A0425) received December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown repair necessitated by restorative material failure (D2980) provided March 8, 2021.
You asked the Plan to pre-approve the crown repair necessitated by restorative material failure. You say that this service should be covered at 50% as a major dental service. The Plan denied your request. The Plan says this service is not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the crown repair necessitated by restorative material failure (D2980) provided March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220) provided on March 22, 2021.
You asked the Plan to pay for an intraoral periapical radiographic image. You say that the service at issue was medically necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 an intraoral periapical radiographic image (D0220) provided on March 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psych services.
You asked the Plan to pre-approve continued inpatient psych services. You say that you feel the enrollee requires this treatment. 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 inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psych services.
Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has shown no mood instability, thoughts of harming herself or others. The enrollee did not have any delusions or hallucinations and did not have any auditory or visual hallucinations. The enrollee was cooperative with care and actively involved in treatment. The enrollee was able to care for her needs. The documentation supports that the enrollee could be treated in a lesser restrictive setting. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psych services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psych services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an eye exam and eyeglasses provided on
January 23, 2021.
You asked the Plan to reimburse you for the eye exam and eyeglasses. The Plan denied your request. The Plan says the servicing provider is not participating in the Plan's vision network and you do not have out-of-network coverage.
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. The Plan covers these services when provided by the Plan's vision provider. We looked at the file and the Plan's rules. The file shows that the eye exam and the eyeglasses were not provided by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for an eye exam and eyeglasses provided on January 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lenses provided on February 20, 2021.
You asked the Plan to pay for the progressive lenses. You say that you fell on your driveway and scratched your eyeglass lenses, and you could no longer see out of them. The Plan denied your request. The Plan says the last date of service in which you obtained a complete set of glasses was June 8, 2020. You will be eligible again to receive the eyewear benefit on January 1, 2022.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every two years.
We looked at the file and the Plan's rules. The file shows that you received the eyewear benefit on June 8, 2020 and you will be eligible to receive the eyewear benefit again on January 1, 2022. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lenses provided on February 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on April 8, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that the X-ray was to check your aspiration pneumonia to see if your lungs were clear. 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 $110 copayment for basic radiological services for outpatient hospital services. You received an X-ray at an outpatient hospital facility on April 8, 2021. Therefore, you are responsible to pay the allowed amount of $81.59, which is less than the $110 copayment.
You have been asked to pay $81.59 for an X-ray. An X-ray 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 for an X-ray provided on April 8,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator device.
You asked the Plan to pre-approve auricular peripheral nerve stimulator device. You say that your device is not an auricular acupuncture device, and your goal is to help alleviate the enrollee's pain and increase the ability to participate in day-to-day activities while reducing or alleviating the need for opioid medications. The Plan denied your request. The Plan says use of this device is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of auricular peripheral nerve stimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular peripheral nerve stimulator device.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram and the ultrasound provided on March 8, 2021.
You asked the Plan to waive the copayment for the diagnostic mammogram and the ultrasound. You say that you feel all diagnostic services should be covered in full. You say you were told to have a spot rechecked in six months. The Plan denied your request. The Plan says you have been asked to pay 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 Medicare-covered x-ray and ultrasounds.
You have been asked to pay a $0 copayment, which is less than the standard amount for the diagnostic mammogram. You have been asked to a $10 copayment for the ultrasound. The diagnostic mammogram and the ultrasound fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic mammogram and the ultrasound provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 31, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that a COVID-19 vaccine caused muscle weakness and you request that all visits related to it be fully covered. 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 $45 copayment for each specialist visit. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit 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 for a specialist visit provided on March 31, 2021.
We note your complaint that a COVID-19 vaccine caused you muscle weakness. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210), and an unspecified preventive procedure (D1999) provided on March 16, 2021.
You asked the Plan to pay for an intraoral complete series of radiographic images, and an unspecified preventive procedure. You say that you were not aware this type of service would not be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210), and an unspecified preventive procedure (D1999) provided on March 16, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, 84153, 85025),
chemotherapy administration (96472), and the Leuprolide acetate injection (J9217) rendered by the out of
network (OON) provider on January 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 laboratory services (80053, 84153, 85025), chemotherapy administration
(96472), and the Leuprolide acetate injection (J9217) rendered by the out of network (OON) provider on
January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic.
You asked the Plan to pre-approve Ozempic. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
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-approve Ozempic.
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.