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

We decided that the Plan does not have to waive the copayment for physician's services or pay for a
computerized corneal topography provided on December 9, 2020.
You asked the Plan to waive the copayment for the physician's services and pay for the computerized corneal
topography. The Plan denied your request. The Plan says the correct copayment was applied to the claim for
the specialist office visit. Also, the Plan does not cover computerized corneal topography under the medical
vision benefit or the supplemental vision benefit.
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 $40
copayment for physician/practitioner services, including doctor's office visits, specialist office.
You have been asked to pay a $40 copayment for the physician's services. The physician's services falls within
the physician/practitioner services, including doctor's office visits, specialist office 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. Also, the file shows that
the Plan does not provide coverage for computerized corneal topography under the medical vision benefit or
the supplemental vision benefit. Therefore, we decided that the Plan does not have to waive the copayment for
physician's services or pay for a computerized corneal topography provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital observation provided on January 19, 2021.

You asked the Plan to waive the copayment for the hospital observation. You say that you were advised there would be no copayment. 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 $250 copayment per visit for Medicare-covered outpatient observation services.

You have been asked to pay a $250 copayment for the hospital observation. The hospital observation falls within the "Outpatient hospital observation" 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 hospital observation provided on January 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmic ultrasound provided on February 22, 2021.

You asked the Plan to waive the copayment for an ophthalmic ultrasound. You say that you disagree with having to pay the full allowed amount and feel that you should only owe a copayment or coinsurance and that the Plan should pay a portion of the cost. 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 $150 copayment for radiological diagnostic services. 

You have been asked to pay the allowed amount of $113.87, which is less than the $150 copayment for an ophthalmic ultrasound. An ophthalmic ultrasound 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 ophthalmic ultrasound provided on February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), a crown (D2740), and a core buildup (D2950) provided on December 10, 2020.

You asked the Plan to pay for an intraoral periapical radiographic image, a crown, and a core buildup. You say that you want the Plan to pay. You are allowed to see an out-of-network provider. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image, a crown, and a core buildup have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0220), a crown (D2740), and a core buildup (D2950) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view (D0380), apicoectomy (D3421), retrograde filling (D3430), and first intraoral periapical x-ray (D0220) provided on October 13, 2020, and November 3, 2020.
You asked the Plan to pay for cone beam CT image capture, apicoectomy, retrograde filling, and first intraoral periapical x-ray. You say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says the cone beam CT image capture, apicoectomy, and retrograde filling are not covered services. The Plan also says that the first intraoral periapical x-ray exceeds the allowed frequency for the time period.
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 cone beam CT image capture, apicoectomy, and retrograde filling are not among those covered under this benefit. The contract says that first intraoral periapical x-ray (D0220) is limited to up to 6 periapical films every 2 calendar years. The record shows that you received a first intraoral periapical x-ray (D0220) on March 12, 2019, and your periapical x-ray benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam CT image capture with limited field of view (D0380), apicoectomy (D3421), retrograde filling (D3430), and first intraoral periapical x-ray (D0220) provided on October 13, 2020, and November 3, 2020.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is a 51-year-old female who was admitted to the current acute care hospital with acute respiratory failure, acute metabolic encephalopathy requiring mechanical ventilation and bronchodilators. The patient appears to be improving and only requires short-term additional acute care services for additional monitoring and treatment that can safely be received at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon when treatment has completed.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), periapical x-ray (D0220), and the 2 fillings (D2392) provided from November 10, 2020, to November 23, 2020.
You asked the Plan to pay the in network rate for the x-ray and 2 fillings. You say that you did not realize that the dentist was out of network. You say that you would like these services to be reprocessed and covered in network as a one time exception. You also say that this would be an unexpected hardship for the enrollee. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service. The Plan says that filling are not listed as covered services either.
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 periapical x-ray and 2 fillings are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for the limited oral evaluation (D0140), periapical x-ray (D0220), and the 2 fillings (D2392) provided from November 10, 2020, to November 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy 50 mg tablet.
You asked the Plan to pre-approve Ubrelvy. You say that this requested drug is medically necessary. The Plan denied your request. The Plan says this medication is not covered under your 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 Ubrelvy 50 mg tablet.
Benefits for Ubrelvy 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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears more stable but is still requiring additional short-term acute care services for weaning off ventilation and vasopressor support that can safely be completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer may be considered when the patient is more stable and treatment has been completed.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health/hospice aide services in home health or hospice settings, each 15 minutes(G0156).
You asked the Plan to pre-approve the home health aide services. You say that you had a stroke and have been unable to do things on your own. You are using a walker and wheelchair due to the risk of falling and generalized weakness. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested home health services.
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 the home health aide services.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation in the available records that the enrollee is receiving a qualifying skilled home health service. Based on the medical records provided here is no documentation that the home health aide services are reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. There is no documentation in the available records that the enrollee is receiving a qualifying skilled home health service. 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 home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health/hospice aide services in home health or hospice settings, each 15 minutes(G0156).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from September 11, 2020, to November 12, 2020.
You asked the Plan to waive the copayment for the SNF care. You say that you were unaware you would be charged $178 a day, after day 21. You say you want the Plan to overturn this and pay some of the bill. 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 $20 copayment per day, days 1 to 20 and a $178 copayment per day, days 21 to 100 per benefit period at a skilled nursing facility.
You have been asked to pay a $2,262.60 copayment for the SNF care. The SNF care falls within the "Skilled
nursing facility (SNF) care" benefit category. See chart below.
Dates of Service Service SNF Days Copayment Day Count Member
Liability
September 11, 2020 to
September 30, 2020
SNF care 1-20 $20 20 $0 - This is less
than the
standard
copayment
amount.
October 1, 2020 to
October 31, 2020
SNF care 21-51 $178 31 $2,262.60 -
This is less than
the standard
copayment
amount.
November 1, 2020 to
November 12, 2020
SNF care 52-63 $178 11 $0 - This is less
than the
standard
copayment
amount.
Total $2,262.60
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 SNF care provided from September 11, 2020, to
November 12, 2020.
Your complaint about the poor conditions in the facility 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a foot insert (L3000) provided on October 8, 2020.

You asked the Plan to pay for a foot insert. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a required modifier.

The Plan must follow Medicare rules. Medicare rules say that the right (RT) and/or left (LT) modifiers must be used with all footwear codes. 

We looked at the file and Medicare rules. The footwear at issue was not billed with a right or left modifier. Based on this information, we decided that Medicare rules for coverage of a foot insert have not been met. Therefore, we decided that the Plan does not have to pay for a foot insert (L3000) provided on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on January 27, 2021.

You asked the Plan to pay an additional amount for the eyeglasses. You say that you believe that $139 is a lot to pay out-of-pocket and you may have been billed this amount in error. The Plan denied your request. The Plan says the correct eyewear allowance of $100, plus a 20% discount was applied to the claim.

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.

We looked at the file and the Plan's rules. The file shows that Plan has paid the correct eyewear allowance of $100, plus a 20% discount. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 10, 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 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 subsequent nursing facility care provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on January 11, 2021.

You asked the Plan to pay for the eyeglasses. You say that the person in the provider's optical department
informed you that you were entitled to two sets of eyeglasses. The Plan denied your request. The Plan says the
rendering provider is not a participating provider.

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 when provided from a network optical provider.

We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
network optical provider. Based on this information, we decided that the Plan's rules for coverage of the
eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided
on January 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 18, 2021.

You asked the Plan to pay for the ambulance services. You say that you were following the Covid executive order to be treated in place by the medics. 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 February 18, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a crown (D2740), and a core buildup (D2950) provided on February 10, 2021.
You asked the Plan to pay an additional amount for a crown, and a core buildup. You say that you were not aware that the annual allowance was $1000. The Plan denied your request. The Plan says the crown is a covered benefit, however the benefit maximum had been met. The core buildup is not a covered service.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown, and a core buildup have not been met. Specifically, the record shows that you had exhausted your dental benefit maximum. Additionally, a core buildup is not a covered service. Therefore, we
decided that the Plan does not have to pay an additional amount for a crown (D2740), and a core buildup
(D2950) provided on February 10, 2021.