Complaints

• Initial Complaint

  01/03/2025

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  I have vision benefits through upmc for life policy.my benefits give me $200 towards frames it pays for eye exam and lenses. I got different type of lense that according to my explanation of benefits was and additional $60 charge.also looking at (eob) my frames where $240 so that would be an additional $40. According to (eob) I should of been charged $60 for upgrade on lenses and $40 for frames totaling $100 total to pay to my eye dr. My eye doctor charged me $230 and i paid it. Ive contacted upmc 5 times to verify to my eye dr that charge should of been $100 instead of $230. To no avail upmc cant seem to verify to my eye dr. That accordjng to there own (eob) i should of been charged $100 instead of the$230 . Ive been hung up on referred to 3 different people with no resolution to problem .just being told there working on it. Its either covered or not dont understand what there working on.I spoke to vendor (my eye dr) and there waiting for upmc to answer them.I pay for upmc insurance thsts who im dealing with not vendor or there 3rd party nv vision company and they cant give me any explanation so i can get.my refund for overchage.

  Business response

  01/15/2025

  
  UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter dated January 3, 2025 as well as the accompanying complaint. 
  

  The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Better Business Bureau ("BBB") regarding this complaint. However, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly or otherwise outreach to the affected individual with a more detailed response. 
  

  If a HIPPA-compliant authorization is provided, UPMCHP respectfully requests a short extension in order to fully address the matters detailed in the complaint in a written response to the BBB. 
  

  Should you have any further questions, please contact me at ************. 
  

  Respectfully Submitted, 
  

  Ashton H*****, Esquire 
  Staff Attorney 
  

  
  

   

• Initial Complaint

  01/02/2025

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Resolved

  More info

  **** offered a $15.gas card at ****** for looking at their information, which I did... I finally did switch to **** from Aetna, and I'm very sorry that I did... I contacted **** on this missing ****** gas card on 9/22/24....10/14/24..12/9/24..I talked to **** ******, and today twice they hung up on me.!!!. They owe me a $15 ****** gift card. They've made this offer to 2 of my friends and my sister in law and never follow thru with offer... They need to be held accountable...

  Customer response

  01/06/2025

  See attachments.

  Business response

  01/13/2025

  Dear *** ******: 

  UPMC for Life (UPMCFL) has received and reviewed your letter dated January 2, 2025 as well as the Authorization to Release Health Information signed by ****** **** Please accept the following as ******'s response to your letter and the accompanying complaint filed by *** **** 
  

  *** ***** complaint stems from issues with receipt of a complimentary gift card. According to our records. *** *** is enrolled in a UPMC for Life **************************************************** plan. 
  

  As noted in *** ***** complaint, she received a flyer from ****** offering a complimentary $15 gas gift card for requesting information about certain ****** plans. *** *** also stated in her complaint that she contacted ****** on various occasions to inquire about the status of her gift card. Upon review by ******, we were unable to locate any calls from *** *** to UPMCFL related to the gift card. 
  

  However, in efforts to resolve *** ***** complaint, ****** will mail a $15 gas gift card to *** **** The gift card may take up to ten business days to be delivered. 
  

  Should you have any further questions, please contact me at ************* 
  

  Respectfully Submitted, 
  

  ****** ******, Esquire 
  

  Staff Attorney

  UPMC Health Plan 
  

  
  

  
  

  Customer response

  01/13/2025

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. 
  
  Regards,
  
  ****** ***

• Initial Complaint

  12/05/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  I have my UPMC Health Insurance on auto pay. However, they said they haven't billed the last two months because they didn't have my updated Credit Card Expiration Date because unlike the majority of merchants do not have the API to get this information. They said they sent out notices in the mail, but I did not receive them. Instead, when I log into my ****** account I see that my insurance is still active and that I received my card for the following year. Now I can't get my life-saving medication because they terminated coverage. I have tried speaking to a supervisor and they said they can't undo what they have done in the system and that they are okay if I die.

  Business response

  12/13/2024

  UPMC Health Plan, Inc. (“UPMCHP”) has received and reviewed your letter dated December 5, 2024 as well as
  the accompanying complaint.

  The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose
  protected health information. Without a HIPAA-compliant authorization, UPMCHP is unable to provide a response
  to the Better Business Bureau regarding this complaint. However, UPMCHP will determine whether the affected
  individual is a UPMCHP member and, if so, will respond directly or otherwise outreach to the affected individual
  with a more detailed response.

• Initial Complaint

  11/05/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  **** refuses to cover an antiobesity agent though I meet all required prescribing criteria. I pay a lot for my copays and insurance and I am disgusted that **** would rather pay for invasive bariatric surgery than approve a temporary prescription.

  Business response

  12/04/2024

  UPMC Health Plan (****HP) has received and reviewed your letter dated November 5, 2024, as well as the
  Authorization to Release Health Information signed by ****** *******. Please accept the following as ****HPs
  response to your letter and the accompanying complaint filed by Ms. ****************** ******** complaint stems from issues with ****HPs denial of a prior authorization for Wegovy 0.25
  MG/0.5 ML Pen. According to our records, Ms. ******* is enrolled in the **** ****************** Provider
  Organization (EPO) Premium Network plan for the 2024 benefit year.

  Under certain circumstances, prescription drugs and medical services that may otherwise be covered are excluded
  from coverage under a members benefit plan. These circumstances are known as exclusions and are detailed in
  the members Certificate of Coverage (***), which is the contract between the member and ******. One
  such exclusion includes drugs and services provided to treat weight reduction. The *** states specifically under
  exclusion 39 regarding weight reduction:

  Weight reduction programs not included in the ******************* Reference Guide. Weight
  reduction programs, including all related diagnostic testing and other services, except when such
  coverage is required by the *************** Act. Anti-obesity medication, including, but not limited
  to, appetite suppressants and ****** inhibitors unless you have coverage for anti-obesity
  medications in your Prescription Medication Schedule of Benefits. 1

  According to our records, Ms. ******** provider, ***** *******, submitted a Prior Authorization Form for the
  medication Wegovy 0.25 MG/0.5ML Pen to treat the diagnosis of obesity on November 5, 2024. ****** denied
  the request on November 5, 2024, because drugs used for weight loss are not a covered benefit, as noted above in
  Ms. ******** ***.

  If Ms. ******* is dissatisfied with the denial, she may exercise her internal appeal rights with ******. As detailed
  in the ***, Ms. ******* may file an appeal within 180 days of the date on which the denial occurred.2 She may
  call the *************** phone number on her member ID card to file an appeal.

  Should you have any further questions, please contact our office.

  Respectfully Submitted,
  ****** ******, Esq.
  Staff Attorney
  UPMC Health Plan

   

  1 See 2024 Certificate of Coverage, page 30.

  2 See 2024 Certificate of Coverage, Resolving Disputes with UPMC Health Plan.
  

   

   

  Customer response

  12/05/2024

  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
  
  I have already tried appealing this last time we tried to get this approved. 
  
  Regards,
  
  ****** *******

• Initial Complaint

  09/27/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I have for years now in past received mailings from UPMC For Life for **** *****, my sister-in-law who passed away about 2-3 years ago. Also, for the past year, I have received mail from UPMC For Life ******* *****, my mother who passed away 11/2023. I have written the firm and have called and talked to the firm by phone and in past month when speaking to *** I was told this would be taken care of, but it has not since I just got a letter for my mom about a week or so ago. The mailings come to ***************************************** which is both of theirs last known residence and now my residence. I tried a couple of ways to get this resolved but no matter what I have done the mailings continue for both of my deceased relatives. Please help me to get this firm to stop the mailings for these are two people who cannot receive this mail and I personally have no use for the mail, etc.

  Business response

  10/08/2024

  UPMC Health Plan****** (UPMCHP) has received and reviewed your letter dated September 27, 2024, regarding 
  Mr. ***** ****** receipt of marketing material from ****** related to its ******** Advantage product. 
  Specifically, Mr. ***** complains he has been receiving unsolicited mail from UPMC for Life on behalf of his late 
  sister-in-law **** ***** and late mother ******* ***** despite having notified UPMCHP. 

  
  Upon investigation of this matter, ****** has determined that materials sent to Mr. ****** home were marketing 
  related. ****** understands the frustration this situation has caused and has taken appropriate steps to remove 
  Ms. **** *****, Ms. ******* *****, and their corresponding home address from UPMC for Lifes marketing database. 
  Please note that we supply mailing lists to our marketing vendors several weeks in advance, so Mr. ***** may 
  receive additional marketing materials after receipt of this correspondence. 

  
  We apologize for any inconvenience to Mr. ***** and thanks the Bureau for bringing this matter to our attention. 
  Should you have any further questions, please contact me at ************. 

  
  Respectfully Submitted, 

  
  ******* Rongxuan **, Esq. 
  Staff Attorney 
  UPMC Health Plan

  Customer response

  10/08/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. I sincerely hope for resolve with this matter as of to date and, if not, I will be forced to continue filing complaints, if in due time, this issue with both my mother (*******) and Sister-In-Law (****) not receiving any mail directly or indirectly from this firm, are not resolved. 
  
  Regards,
  
  ***** *****

  Customer response

  10/28/2024

  I received a mailing from 'UPMC for Life' addressed to ******* ***** (my deceased mother) and filed a complaint to stop the practice, but it appears they will not stop. I also been receiving same mailings for ***** ***** (my deceased father) too. I have sent two faxes to the Corporate Attorney as well but no response to date. The Mailings need to stop and all I can do now is continue to file complaints since now not only my mother is still receiving the mailings but now my father as well.

  Customer response

  10/29/2024

  Please see attached.

  Business response

  11/04/2024

  See attached.

  Customer response

  11/05/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me for the most part. If after a month (12/5/24) I am still receiving marketing mail with **** on it for either **** *****, ******* *****, or ***** *****, I will NOT call UPMC phone number **************** because they, I have found, are useless and besides I have contacted them in the past for these situations but despite them telling me it will be resolved, etc., the same problem(s) continued on occurring. I WILL continue to fax the ******************* for resolve since this seems to be the most effective way for resolving my concerns and issues in receiving any more mail addressed to my deceased family relatives. If **** office has a problem my circumventing the ******* via phone if the issues continue, then I ask them to place themselves in my shoes because I tried to do everything to cease the mailings to no avail. Please expect me to fax the ********** of **** in the future if I continue to get these mailings. Thank you.
  
  Regards,
  
  ***** *****

• Initial Complaint

  09/17/2024

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  Ok every year though **** give $ 165 in rewards on our health benefits card you get $30 for your yearly wellness exam you get $ 25 for your diabetic eye exam you get $ 50 for your annual breast mammogram and if I'm not mistaken you get $ ******************************************************************************** a stool sample to a lab to check for colon cancer well i did my eye exam got my money for that got my rewards for my yearly wellness exam but in June when I had my sonogram mammogram due to a messed up rotator cup surgery I call my ** to set up the sonogram mammogram upmc said that was fine but the ************************** billed it wrong they billed it as a Diagnostic instead of a preventive so upmc call me on 9-7-24v and told me that they would call ****************** billing to have them resubmit it as a prophylactic but they have still to do it i called today and was told that they have to investage it but i don't know what the ** *** look at my test after my mammogram said there was no signee of cancer i never have had breast cancer i get checked ever year and every single one of my mammograms come back negative for cancer so i don't know what there to investigate now they say i have to wait another ***** days iv all ready waited almost 4 months this is not fair because ****************** sent in the wrong code not there are refusing to call the hospital to fix it

  Business response

  09/27/2024

  UPMC Health Plan****** ("UPMCHP") has received and reviewed your letter dated September 17, 2024, as well as the accompanying complaint. 

  
  The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Better Business Bureau regarding this complaint. However, UPMCHP will determine whether the affected individual is a ****** member and, if so, will respond directly or otherwise outreach to the affected individual with a more detailed response. 

  
  Should you have any further questions, please contact me at ************.

  
  Respectfully Submitted, 
  
  "*******" ******** **, Esq. 
  Staff Attorney 
  UPMC Health Plan 
  

  
  

• Initial Complaint

  09/13/2024

  Complaint Type:

  Billing Issues

  Status:

  Resolved

  More info

  why does my health plan not pay for my full dental plan as it was months ago. UPMC sent me a bill for over $1056.00 for my dental and they want me to pay the rest but I can not pay the whole bill. Is there a reason for UPMC to not pay my full amount of my dental bill completely. Will you find out why UPMC can't pay my whole bill completely instead sending me this big bill. Please help me get this bill off my back with my health insurance with UPMC for life company, Thank you for your help

  Business response

  09/23/2024

  UPMC Health Plan, Inc. (“UPMCHP") has received and reviewed your letter dated September 13, 2024 as well as the accompanying complaint. 

  
  The above-referenced complaint did not include a HIPAA authorization that would allow UPMCHP to disclose protected health information. Without a HIPAA-compliant authorization, UPMCHP is unable to provide a response to the Better Business Bureau regarding this complaint. However, UPMCHP will determine whether the affected individual is a UPMCHP member and, if so, will respond directly or otherwise outreach to the affected individual with a more detailed response. 

  
  Should you have any further questions, please contact me at ###-###-####. 

  
  Respectfully Submitted, 

  Ashton H*****, Esquire Staff Attorney UPMC Health Plan 
  

  
  

  Customer response

  09/24/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. 
  
  Regards,
  
  ******* *****

• Initial Complaint

  09/06/2024

  Complaint Type:

  Customer Service Issues

  Status:

  Answered

  More info

  I wish to bring to the attention of the BBB the deeply rooted, customer service issues that exist within the 800LB Gorilla Monopoly known as UPMC. I opened a dental dispute back in July #********** and have basically been ignored by numerous supervisors (Jimeece, *** ***, ******* ****** and *****) and the Health Plan as a whole. See my email attached where I requested action on 8-10, 8-14, 8-28 and 9-5. I have been met with platitudes and numerous apologies, but at the end of the day the Health Plan has failed the consumer. A copy is also being filed with the ***********************.

  Customer response

  09/18/2024

  See attached.

  Business response

  09/30/2024

  UPMC Health Plan****** (******) has received and reviewed your letter dated September 6, 2024, as well as 
  the Authorization to Release Health Information signed by ***** ****. Mr. ***** complaint relates to issues 
  surrounding his dental benefits coverage. ******* records indicate, at all relevant times, he was enrolled in a 
  **** Dental Advantage Individual Basic adult buy-up dental plan purchased through the **** Marketplace 
  and offered by **** Health ************** 

  
  According to ****** records, Mr. **** received dental services from in-network provider Dr. ************************ on June 26, 2024. ****** then received a claim related to those services with a procedure code of 
  D2393 for Resin-Based Composite Three Surfaces and a billed amount of $300. Although only optional and not 
  required, ****HP has no record of receiving any type of predetermination request or outreach to verify whether 
  the intended services would be covered prior to the services being rendered. After the claim was received, it was 
  processed in accordance with Mr. ***** dental coverage and was denied because it was a Class II service, which 
  is a non-covered benefit. However, members are eligible for a 20% discount on Class II services if they are 
  rendered by an in-network provider.

  
  In this case, based on the billed amount, Mr. **** would owe $240 for the 
  services in question.

  
  On July 29, 2024, Mr. **** contacted the ****HP Online Help Desk to appeal the adverse benefit 
  determination related to the claim. Additionally, he contacted ****** several times between July 9th and 
  September 6th to inquire about the providers bill and status of his appeal. During these conversations, he advised 
  ****HP that he paid roughly $119 at the providers office on the day the services were rendered. Further, after 
  ****HP processed the claim for those services, the providers office sent Mr. **** another bill for 
  approximately $121. On August 29, 2024, during one of the telephonic conversations, ****HP noted that the 
  review of Mr. ***** appeal request had not finished processing yet. The issue was immediately escalated to 
  leadership and his request was flagged for expedited review. A complete review was conducted, and a written 
  response was issued on September 9, 2024, explaining the claim for dental services had processed correctly in 
  accordance with coding guidelines and Mr. ***** dental benefits.
  

  
   
  ****HP recognizes an error occurred specifically in relation to the processing of Mr. ***** appeal request, 
  which was originally submitted on July 29, 2024. However, the claim in question still processed appropriately and 
  in accordance with his dental benefits coverage. Mr. **** is responsible for the costs of Class II dental services 
  but is eligible for a 20% discount on the billed amount. Should you have any further questions, please feel free to 
  contact our office.

  
  Respectfully Submitted,
  
  ******* ********, Esq.
  Staff Attorney
  **** Legal Department
  UPMC Health Plan

  Customer response

  10/01/2024

  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and have determined that this does not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
  
  The junior attorney goes on and on and on about the facts of this matter and how the claim processed correctly, none of which have ever been in dispute. I have already paid the dentist the money that we all agree is owed and the matter is closed on that front.

  As stated in my original complaint, this case surrounds only the deeply rooted failures in customer service that I have received and my dentist has received from multiple UPMC health plan representatives on multiple occasions over the past two months. The incomplete, incorrect, and incoherent misrepresentations made to me by this very sad organization resulted in me and my dentist wasting a significant amount of time. My dentist, in fact, did reach out to the health plan on my behalf and was also given incorrect, incomplete and incoherent information. The **** explanation of benefits listed in the **** app also contained severe misrepresentations about  financial responsibilities.

  I have also had an opportunity to share productive feedback with ****** ****** in **** executive management. It is my understanding that she is in the process of providing much needed training and retraining to her untrained staff by allowing them to review the numerous phone calls and learn from the severe errors that were communicated to me.

  It is curious to me that the junior attorney chooses to bury the deeply rooted, internal customer service issues in one sentence at the end of the letter and fails big time with even offering an apology. I assume this is strategic and intentional, and it is not lost on me. I trust it is not lost on the BBB and general public.

  Yet, this result is predictable and expected when you have two corrupt entities, Highmark and UPMC, delivering healthcare in the region. The lack of competition fosters a lack of accountability for the business and forces the consumer to deal with it since there is "no where else to go". UPMCs  response tells me all I need to know.

  No need to waste more time on this very sad excuse for a healthcare provider. Please close my case as "business responded, customer remains dissatisfied". If one person reads this case and decides against using ****, then mission completed. Respectfully submitted, *****

• Initial Complaint

  10/10/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Resolved

  More info

  I have told UPMC for Life numerous times at every address that I have lived at since 2016 that I am not eligible for Medicare and to stop mailing me advertisements for them. They have followed me to every address. I would like for this to stop and actually have them listen to me!

  Business response

  10/18/2023

  UPMC Health Plan, Inc. (“UPMCHP") has received and reviewed your letter dated October 11, 2023, as well as the accompanied complaint filed by **** ***********. Mr. ***********'s complaint relates marketing materials received from UPMC for Life,' UPMCHP's Medicare Advantage product. Our enrollment records indicate that Mr. *********** is not currently enrolled in a health insurance product offered by UPMCHP. 

  According to Mr. ***********'s complaint, he has been receiving unwanted marketing materials related to UPMC for Life since 2016. He further states that he is not eligible for Medicare and has requested not to be contacted by UPMC for Life. This matter was referred to the UPMC for Life Marketing Department and they have confirmed that Mr. ***********'s name and the address listed in the complaint have been placed on the "Do Not Contact" list in the UPMC for Life mailing database as of October 16, 2023. 

  Please note, the UPMCHP is only able assist with the suppression of mailings that originate from within the UPMC Insurance Services Division. UPMCHP is unable to stop materials being sent by other UPMC entities or departments outside of UPMCHP. UPMC is an integrated delivery and finance system (IDFS) that is made up of multiple divisions, as well as many different medical professionals, providers, hospitals, doctor's offices, and outpatient facilities. If Mr. *********** receives any future unwanted mailing, we request that he provide us with the sender's return address. This information will help to identify the source of the mailings and assist in directing his request to the appropriate party to prevent future mailings. 

  Should you have any further questions, please contact our department. 

  Respectfully Submitted, 
  

  Steven *. V***** **** 
  Staff Attorney 
  

  
  

  Customer response

  10/18/2023

  [A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me. 
  
  Regards,
  
  **** ***********

• Initial Complaint

  08/28/2023

  Complaint Type:

  Service or Repair Issues

  Status:

  Answered

  More info

  November 2022 I got approved for Waiver/Midas program for the disabled and underfunded US citizens. They cover Medicare/Medicaid premiums, issue a Health Care Coordinator for any and all concerns. Since February of 2023 I have had an infection that started in my tooth which they knew about but could not find me Dental care. I have been on antibiotics since. The infection is now in my blood through out my body. I asked for a Home Health Care aid. That took 3 months. My aide left for a month or so but I had no back up. Some times, here and there, someone would show up but mostly on my own. I'm in a wheelchair, 3 back surgeries, Neck surgery, osteoarthritis through out my body, migraines, enlarged heart, high blood pressure, high cholesterol, COPD and a form of MS. Spinal Stenosis and now, unusual bleeding where I shouldn't be. I got approved 25 hours a week for a HHCA but required more because of all the medical issues and emotional support getting back and forth to my appointments. They gave me 5 hours more, I asked for UP TO 50, just in case. Got denied. Requested another assessment for 40hrs per week. Still waiting. An automatic door lock was too be installed 4 months ago. Still waiting. My PCP along with myself requested medication for weight loss. I'm overweight, bad heart and lungs with high cholesterol and even my brother has Diabetes, not to mention I can't exercise in a wheelchair, dizzy, nauseous, migraines and can't breathe very well. No. Denied. My mom died the same age I am now. I've barely been out of bed since January, Feb of this year. I'm still waiting to get to a Dentist that won't refuse to work on me because, " UPMC doesn't pay for anything." Sent me home.

  Business response

  09/15/2023

  UPMC Health Plan, Inc. ("UPMCHP") has received and reviewed your letter dated August 29, 2023 as well as the accompanying complaint. We are also in receipt of the HIPAA authorization form on September 13, 2023. 

  UPMCHP's enrollment records indicate that at all relevant times Ms. ***** was a participant in UPMC Community HealthChoices ("UPMC-CHC”), a Community HealthChoices Managed Care Organization (“CHC- MCO") and product of UPMC for You, Inc. Community HealthChoices (“CHC”) is Pennsylvania's Medical Assistance (Medicaid) managed care program that includes physical health benefits and long-term services and supports (LTSS). Ms. ***** is also a member of UPMC for Life Complete Care, a dual-eligible Special Needs Plan (D-SNP) and a product of UPMC for You, Inc. In her complaint with your office, Ms. ***** expresses frustration with several coverage issues. 

   

  Issues with Dental Care

  On March 22, 2023, Ms. *****'s service coordinator contacted UPMCHP Member Services for assistance in locating an in-network dental provider for Ms. ***** under her D-SNP plan. The service coordinator was provided the names of several dentists. On March 27, 2023, Ms. ***** contacted UPMCHP Member Services for assistance in locating a dental provider and was given the name of a dentist that was in network. 

  On August 2, 2023, Ms. ***** contacted UPMCHP member services to locate an in-network endodontist, and an endodontist within 50 miles of her home could not be located. The member was offered an organization determination under the D-SNP plan, and the member declined. 
  

  On August 8, 2023, Ms. ***** contacted member services to locate an endodontist, and was again informed that there was not one within 50 miles of her home. 
  

  On August 29, 2023, Ms. *****'s service coordinator contacted UPMCHP's Member Services to ask about Ms. *****'s benefits for out-of-network dental services. The service coordinator was informed that the member would have to contact UPMCHP for an organization determination. 
  

  On August 30, 2023, the service coordinator contacted UPMCHP on behalf of the member to request an out-of- network organization determination. No action was taken on that call. 
  

  Our records indicate that Ms. ***** visited Dr. Siddhant Gaidhane of Sadler Health Center Corporation on September 6, 2023, who is an in-network provider. Should Ms. ***** experience further difficulty, we encourage her to contact Member Services for assistance. 
  

   

  Issues with Medication 
  

  Ms. ***** notes that her coverage was denied for a weight loss medication. On March 10, 2023, Ms. ***** filed an expedited coverage determination under her Medicare plan for Wegovy. The coverage determination was denied on March 10, 2023 because Wegovy is not covered under Medicare Part D for the treatment and maintenance of weight loss. Section 1927(d)(2) of the Social Security Act specifically excludes from coverage drugs "used for anorexia, weight loss, or weight gain". As noted in Chapter Six of the Medicare Prescription Drug Manual, "Part D drugs do not include drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1927(d)(2) of the Act." This includes drugs "used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose (i.e., morbid obesity))." 
  

   

  Issues with Home Care 
  

  As a participant with UPMC Community Health Choices, Ms. ***** receives personal assistance services ("PAS"). On July 12, 2023, Ms. ***** requested an increase in her current number of PAS hours from 25 hours per week to 50 hours per week. After review by a medical director, UPMCHP granted 30 hours of PAS, and denied 20 hours because Ms. *****'s assessment determined that her functional needs would be met with 30 PAS per week. On July 13, 2023, Ms. ***** filed an appeal, requesting additional PAS hours. On August 11, 2023, UPMCHP issued a decision upholding the 30 hours of PAS a week. The letter includes all the information relevant to filing a request for an external review and/or a Fair Hearing with the Department of Human Services. 
  

   

  Issues with Automatic Lock Door 
  

  Our records indicate that the request for the automatic door lock was approved on September 8, 2023. If Ms. ***** has not received notice of this approval, we encourage her to contact her Service Coordinator. 

   

  Should you have any further questions, please contact me at  ************. 
  

  Respectfully Submitted, 
  

  Lakshmi D****, Esquire 
  Assistant Counsel 
  UPMC Health Plan 
  

  
  

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