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

We decided that the Plan does not have to waive the copayments for the laboratory work provided on February
24, 2020 to February 27, 2020.
You asked the Plan to waive the copayments for the laboratory work. You say that you should not be
responsible for the copayments. The Plan denied your request. The Plan says you have been charged 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $10 copayment for each Medicare-covered laboratory test.
The enrollee has been asked to pay a $10 copayment for the laboratory work on each date of service. The
laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. This means that the enrollee has been asked to pay the correct amount based on the contract with the
Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.
Therefore, we decided that the Plan does not have to waive the copayments for the laboratory work provided on
February 24, 2020 to February 27, 2020.
Your complaint about the provider's misdiagnosis and negligence 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 pre-approve a power seat elevation system. You asked the Plan to pre-approve the power seat elevation feature (E2300). You say that you need a Group 3 power wheelchair, accessories, and power seat elevation system. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This feature is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided on December 11, 2019.
You asked the Plan to pay for the hearing aid. You say that you were not told there were precertification
requirements. The Plan denied your request. The Plan says that they do not reimburse for devices received from
non-plan hearing network vendors under this supplemental benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when you select a device from the list available through their participating hearing aid
supplier.
We looked at the file, and the Plan's rules. The file indicates you did not get the hearing aid through a
participating hearing aid supplier. Based on this information, we decided that the Plan's rules for coverage of
the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid
provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 28, 2020. You asked the Plan to waive the copayment for the MRI. You say that you were told by a Plan representative that the visit would be covered in full with no deductible. The Plan denied your request. The Plan says you have been charged 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 $200 copayment for all other diagnostic and nuclear medicine radiological services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $200 copayment for the MRI. You have been asked to pay a $184.12 copayment for the MRI. The MRI 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 the MRI provided on January 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation.
You asked the Plan to pre-approve routine transportation. The Plan denied your request. The Plan says that you do not have transportation benefits.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-four or more surfaces or involving incisal angle, tooth
25 (D2335) resin-based composite - three surfaces, tooth 12 (D2393) provided February 17, 2020.
You asked the Plan to pay for the dental services. You say that this is the first time you had used your dental
and you have never had any dental work previously. The Plan denied your request. The Plan says this service
exceeds the benefit limitation.
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 contract says that
restorations are limited to 2 procedures per calendar year. The records show that you had 4 restorations
completed on this same date. The plan had approved resin-based composite, three surfaces, tooth 19 (D2394)
and resin-four or more surfaces, tooth 24. Therefore the 2 additional restorations is not covered as this benefit
is now exhausted.
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 at this time. Therefore, we decided that the Plan does not have to pay
for resin-four or more surfaces or involving incisal angle, tooth 25 (D2335) resin-based composite - three
surfaces, tooth 12 (D2393) provided February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for recement inlay, onlay, veneer or partial coverage restoration, tooth #2 (D2910) provided January 27, 2020.
You asked the Plan to pay for the dental services. You say that you did not need to have a crown made, You have crowns already. Your crown fell out and you just needed to have it put back in. You feel you should be reimbursed. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Services not listed under the list of covered dental procedure codes are not covered. 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 recement inlay, onlay, veneer or partial coverage restoration, tooth #2 (D2910) provided January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendodontic therapy (root canal) tooth 21 (D3320).You asked the Plan to pre-approvethe dental service. You say that tooth 21 can be saved if you do a root canal and core buildup and after that treatment is finished then the enrollee will need a crown.The Plan denied your request. The Plan says this service is not listed as covered under the plan benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveendodontic therapy (root canal) tooth 21 (D3320).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required maximum assistance of two for transfers. The enrollee has decreased tolerance to activity and endurance limiting therapy participation. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does support that the enrollee may benefit from further physical therapy and occupational therapy, but does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe AEDprovided on January 14, 2020.You asked the Plan to pay forthe automatic external defibrillator (K0606). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the enrollee was in an inpatient status at the time the AED was billed.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers.Records show that the automatic external defibrillator (K0606) was used in a hospitalduring an inpatient stay.Therefore, we decided that the Plan does not have to pay forthe AEDprovided on January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 29, 2019. You asked the Plan to pay for the ambulance services. You say that you want patient liability because the ambulance service was not medically necessary. The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle. Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee, complaining of abdominal and tooth pain, was ambulatory, conscious, stable, in no acute respiratory or cardiac distress, and had no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically debilitated. The documentation does not support that you require the supervision by physical medicine and rehabilitation physician or require acute rehab nursing care. The documentation supports that you have low tolerance for activities in therapy. While you may benefit from further physical therapy and occupational therapy, you do not require an intensive therapy program. Your care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the podiatry visit provided on February 24, 2020.
You asked the Plan to reduce the coinsurance for the podiatry visit. You say that you should only have a $10 copayment. You say you cannot afford the 50% coinsurance. The Plan denied your request. The Plan says you have been charged 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 50% coinsurance for Medicare-covered podiatry services at an out-of-network specialist's office. You have been asked to pay $22.02 which is 50% of the allowed amount for the podiatry visit. The allowed amount is $44.04. ($44.04 x 50% = $22.02). The podiatry visit falls within the "Podiatry services" benefit category. The record shows that the provider is out-of-network.
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 reduce the coinsurance for the podiatry visit provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you trust this provider. You say that this doctor is very experienced in auto immune disease. The Plan denied your request. The Plan says there are multiple in-network providers available for these services.
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 a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you want a continuous glucose monitor. The Plan denied your request. The Plan says you are only testing 2 to 3 times a day and only directed to test 3 times a day. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows you are not testing four or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on March 19, 2020.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician.
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 pay for the knee orthosis (L1833) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960). Our reviewer says that criteria for the orthoses is not met. Our physician reviewer found the enrollee's chief complaints were chronic pain, knee left, and chronic pain, shoulder left, documented in 2 separate notes on the same date of service. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder. 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 knee orthosis (L1833) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device (E0652). You say that the enrollee's provider specifically ordered this pneumatic compression pump to use daily. The Plan denied your request. The Plan says a PCD is not covered for the treatment of lymphedema of the extremities alone.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen. We looked at the file and Medicare rules. The enrollee's edema is localized to the extremities. Based on this information we decided that Medicare rules for coverage of the PCD have not been met.
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on October 12, 2019 to
December 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON home health services. You say that you were told authorization was not
necessary. The Plan denied your request. The Plan says the benefit for these services has been exhausted.
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. Plan contract also says that it offers an Easy Travel benefit for
services outside of the state of Idaho. This benefit has a coverage maximum of $2,500 each calendar year.
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. While the Plan offers a benefit that covers
OON services when provided out-of-state, the records show that the enrollee had met the yearly coverage
maximum for this benefit prior to the submission of the claim at issue. Therefore, we decided that the Plan does
not have to pay for the home health services provided on October 12, 2019 to December 9, 2019 by an out of
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oral nutrition supplement.You asked the Plan to pre-approvean oral nutrition supplement. You say that you have GI issues and your stomach hurts every day.The Plan denied your request. The Plan says enteral nutrition for oral intake is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enteral nutrition products administered orally are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of enteral formula (B4150) have not been met. Therefore, we decided that the Plan does not have to pre-approvean oral nutrition supplement.