Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on August 11, 2021.
You asked the Plan to pay for the dental service. You say that you did not request, nor was it communicated to you that a complete series x-ray would be required to complete the standard annual dental check up and cleaning. You also say that you feel excess charge and surprise add on services are not fair. You also say that this service should be covered. The Plan denied your request. The Plan says the complete series x-ray is not listed as 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete series x-ray (D0210) provided on August 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 7, 2021.
You asked the Plan to pay for the limited oral exam. You say that the second evaluation was necessary, and you would like an exception for it to be covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on February 17, 2021. Based on this information, we decided that the Plan's frequency
limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided September 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided on September 11, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the non-emergency ambulance transportation. You say that you needed to be transported back to where you lived and could not be transported by vehicle. You also say that you wanted to go back to where you live for care but were unaware you needed to have prior authorization. The Plan denied your request. The Plan says the provider is not contracted for your plan. The Plan also says that the services were not precertified.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0428) provided on September 11, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on July 27, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that this was a routine checkup. You say that you
were not having any problems and are appealing the panoramic x-ray. The Plan denied your request. The Plan
says the service 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 the panoramic x-ray provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided by optout provider on April 5, 2021.
You asked the Plan to pay for dental services. You say that you were unaware that this provider had opted out. The Plan denied your request. The Plan says this provider is not a participating provider with Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. This provider has opted out from March 8, 2016, to March 8, 2022. Therefore, we decided that the Plan does not have to pay for dental services provided by an optout provider on April 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on January 31, 2021, to February 14, 2021, and May 3, 2021, to May 5, 2020.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not be responsible for this. The Plan denied your request. The Plan says this claim was processed correctly, and the correct copayment has been applied.  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 per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.   You have been asked to pay a $150 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. You are being asked to pay $750 ($150 x 5 days = $750) for dates of service January 31, 2021, to February 14, 2021. You are being asked to pay $450 ($150 x 3 days = $450). The total amount you are being asked to pay is $`,100 ($750 + $450 = $1,200). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 provided by a participating provider on January 31, 2021, to February 14, 2021, and May 3, 2021, to May 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for twenty-five (25) sessions of physical therapy (97110, 97140, 97162) provided from February 23, 2021, to May 24, 2021.  You asked the Plan to waive the copayments for physical therapy. You say that you do not feel it is fair that you are being charged for each visit and you were not advised of the required copayment for these services. The Plan denied your request. The Plan says these copayments were assessed in accordance with your contract. There is a $20 copayment for each Medicare-covered physical therapy visit.  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 for each Medicare-covered physical therapy visit.   You have been asked to pay a $500 copayment for 25 sessions of physical therapy ($20 x 25 visits = $500). 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 twenty-five (25) sessions of physical therapy (97110, 97140, 97162) provided from February 23, 2021, to May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 27, 2021.  You asked the Plan to pay for the dental service. You say that this bill should be covered. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.  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 service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on August 25, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient observation services provided from February 6, 2021, to February 9, 2021.  You asked the Plan to waive the copayment for the outpatient observation. You say that you were advised there would be no cost to you for these services. The Plan denied your request. The Plan says they have reprocessed this claim, and now your copayment has been assessed in accordance with your contract. Outpatient observation services require a $225 copayment.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for outpatient hospital observation.   You have been asked to pay a $225 copayment for the outpatient observation services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient observation services provided from February 6, 2021, to February 9, 2021.   Your complaint about potential misinformation which may have been provided by an agent of the Plan 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from July 31, 2021, to August 1, 2021.  You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you were under the impression that emergency services rendered at in-network facilities were covered completely by your Plan. The Plan denied your request. The Plan says this claim is covered and was processed in accordance with your contract. You are responsible for a $500 copayment per inpatient admission.  
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 $500 copayment per inpatient admission.    
You have been asked to pay a $500 copayment for the inpatient hospital 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 hospital admission and services provided from July 31, 2021, to August 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a TearLab Osmolarity test provided on August 2, 2021.

You asked the Plan to waive the copayment for a TearLab Osmolarity test. The Plan denied your request. The Plan says according to your EOC, you are required to pay a $10 copayment.

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 outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $10 copayment for a TearLab Osmolarity test. The TearLab Osmolarity test 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 a TearLab Osmolarity test provided on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network podiatry services for the enrollee.

You asked the Plan to pre-approve out of network services. You say that this care is medically necessary. The Plan denied your request. The Plan says you are not a network provider.

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. Your office and staff are not network providers 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 out of network podiatry services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing provided from May 1, 2021, through May 29, 2021.

You asked the Plan to pay for medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing. The Plan denied your request. The Plan says the services received were not authorized and are not payable by the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing provided from May 1, 2021, through May 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Dexilant capsule.

You asked the Plan to pre-approve Dexilant. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Dexilant capsule.

Benefits for Dexilant 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies for the enrollee.

You asked the Plan to pre-approve incontinence supplies. You say that these supplies are medically necessary for the enrollee. The Plan denied your request. The Plan says these types of supplies are not covered by Medicare.

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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that services can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided May 21, 2021, to May 23, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you don't feel you should have a copayment for this service. The Plan denied your request. The Plan says the copayment was 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 $325 copayment per day for days 1 through 6 per benefit period for inpatient hospital care. 

You have been asked to pay a total of $975 ($325 copayment x 3 days = $975) for the inpatient hospital services. The inpatient hospital services fall 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 admission and services provided May 21, 2021, to May 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the heart pacemaker implant provided in an outpatient hospital setting on May 20, 2021.

You asked the Plan to waive the coinsurance for the heart pacemaker implant provided in an outpatient hospital setting. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a heart pacemaker implant provided in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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% coinsurance for Prosthetic Devices/Medical Supplies provided in an outpatient hospital setting.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a heart pacemaker implant provided in an outpatient hospital setting on May 20, 2021. You have been asked to pay a 20% coinsurance for the heart pacemaker implant provided in an outpatient hospital setting. The heart pacemaker implant provided in an outpatient hospital setting 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 coinsurance for the heart pacemaker implant provided in an outpatient hospital setting on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sterile water and gloves.

You asked the Plan to pre-approve sterile water and gloves. You say that sterile water and gloves are medically necessary. The Plan denied your request. The Plan says sterile water and gloves are not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that disposable medical supplies are not covered because they are hygienic items that are non-reusable. While sterile water and gloves 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 sterile water and gloves.