Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract surgery provided on August 4,
2020, and August 18, 2020.
You asked the Plan to waive the copayments for cataract surgery. You say that you cannot afford 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 $175
copayment for outpatient surgery, including services provided at ambulatory surgical centers.
You received cataract surgery on August 4, 2020, and August 8, 2020. You are responsible to pay a $175
copayment per each surgery. The total amount you owe is: $175 (copayment) x 2 (surgeries) = $350.
You have been asked to pay the total copayment amount of $350 for cataract surgery. Cataract surgery falls
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers 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 cataract surgery provided
on August 4, 2020, and August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent 15 minute increment of deep sedation/general 
anesthesia (D9223), therapeutic parenteral drug (D9610), and adjunctive procedure (D9999) provided. 
 
You asked the Plan to pay for the deep sedation/general anesthesia, therapeutic parenteral drug, and adjunctive 
procedure. You say that these services were provided on an emergency basis. You also say that you understood 
that as long as your dental bills do not exceed $1,000 per year, the Plan would pay for the services. The Plan 
denied your request. The Plan says these services are not covered benefits under your dental plan. 
 
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 
subsequent 15 minute increment of deep sedation/general anesthesia (D9223), therapeutic parenteral drug 
(D9610), and adjunctive procedure (D9999) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis with contrast (74177) provided on July 2, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 per provider per day for in-network Medicare-covered diagnostic radiology services.  
 
You have been asked to pay a $225 copayment for the in-network Medicare-covered diagnostic radiology 
service provided. 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 adjust the copayment for the computed tomography (CT) 
scan of the abdomen and pelvis with contrast (74177) provided on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 24, 
2020, to March 27, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you thought that 
copayments would be waived. 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 $335 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 24, 2020, to March 27, 2020. Therefore, you are responsible to 
pay a $335 copayment for days 1-3 (March 24, 2020, to March 26, 2020). $335 (copayment) x 3 (inpatient 
days) = $1,005. 
 
You have been asked to pay the total copayment amount of $1,005 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for an inpatient hospital stay from March 24, 2020, to March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trulicity injections. 
 
You asked the Plan to pre-approve Trulicity injections. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Trulicity injections are not covered under the enrollee's 
Medicare Part B 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 Trulicity injections.  
 
Benefits for Trulicity injections 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 17, 2020 and is currently undergoing treatment for COVID-19 and end-stage renal disease. There is no evidence that the enrollee requires services that are not available at the current facility. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The LTACH services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided on March 26, 2020. 
 
You asked the Plan to pay for incontinence supplies. You say that you were told these are a covered service. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on March 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided June 6, 
2020 to June 11, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that You do not feel that 
you should be charged in any way due to the lack of attention to the enrollee's needs while at this facility. There 
was grave lack of attention at both the hospital and rehab. The Plan denied your request. The Plan says this 
claim was processed with the correct copayment applied per the Evidence of Coverage. 
 
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 $300 
copayment for each day for days 1-5 for Medicare covered hospital care.  
 
You have been asked to pay $1,500 ($300 x 5 days = $1,500) for the inpatient hospital stay. The inpatient 
hospital stay falls within the Inpatient hospital care benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient hospital stay provided June 6, 2020 to June 11, 2020.  
 
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus 
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the 
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tubing extension set (S1015) and infection control supplies (S8301) provided. 

You asked the Plan to pay fora tubing extension set  and infection control supplies. You say that these items should be covered.The Plan denied your request. The Plan says these codes are not valid.

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 codes S1015, S8301 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of a tubing extension set  and infection control supplies have not been met.Therefore, we decided that the Plan doesnot have to pay fora tubing extension set (S1015) and infection control supplies (S8301) provided
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for an office visit and testing to be 
provided by the out-of-network provider. 
 
You asked the Plan to pre-approve the physician's services. You say that you are going blind and you have had 
two retina surgeries. You say that you are trying to get a third opinion for surgery with the best retina specialist 
in the USA, which is the requested physician. 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers.  
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services for an office visit and testing to be provided by the  
out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that this is medically necessary. The Plan 
denied your request. The Plan says these are convenience items that are primarily hygienic in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower/bath chair. 
 
You asked the Plan to pre-approve a shower/bath chair. You say that this item is medically necessary. The Plan 
denied your request. The Plan says Medicare does not cover shower/bath chairs. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like to see this doctor because 
he did your last knee replacement. The Plan denied your request. The Plan says there are in-network providers 
available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from May 25, 2020, to June 8, 
2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you are appealing the reimbursement denial of $1,394 for payments made to 
a non -participating provider for chiropractic services rendered from April 8,2020 until May 18,2020. The Plan 
states they have partially approved and reimbursed you $100.44 for 12 chiropractic visits for dates of service 
April 8,2020, April 9,2020, April 10, 2020, April 14, 2020, April 16, 2020, April 20, 2020, April 21, 2020, 
April 23, 2020, April 27, 2020, May 04, 2020, May 11, 2020 and May 18, 2020 as medical records received 
from the provider indicate services were rendered due to urgently needed care from the non -participating 
provider. However, the reimbursement request of $273 for date of service May 25, 2020, June 03, 2020 and 
June 08, 2020 exhausts your 2020 chiropractic service benefit limitation. According to your 2020 Plan contract, 
chiropractor services for routine spinal adjustments is only covered for 12 visits per calendar year. Therefore, 
your request for reimbursement for visits for dates of service May 25, 20, June 03, 20, June 08, 20 have been 
denied. 
 
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 12 chiropract visits are 
covered per year. That benefit was exhausted. Therefore, we decided that the Plan does not have to pay for 
chiropractic services provided from May 25, 2020, to June 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that it is felt that this should be covered. The Plan denied 
your request. The Plan says the criteria for the CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. There is no 
documentation of the number of daily tests and the records only show an order for two daily insulin injections. 
Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
for medical appointments. The Plan denied your request. The Plan says you have 2 trips remaining for your 
transportation benefit which have been approved. Additional trips cannot be authorized. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on July 21, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you disagree with the charges because
you are unhappy with the service the doctor provided. 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 $35
copayment for X-rays.
You have been asked to pay a $35 copayment for an X-ray. An X-ray falls 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
an X-ray provided on July 21, 2020.
We note your complaint that you are unhappy with the service you received from the doctor. 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.