Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physician services rendered to you on October 1, 2019.You asked the Plan to waive the copayment forthese services. You say that you disagree with the charges.The Plandenied 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 $35 copayment for per specialist visit. Review of the file shows that you had a specialist visit on October 1, 2019. You have been asked to pay a $35 copayment these services. These services fall within the specialist visit 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. The file shows that you also received cosmetic services on October 1, 2019 for which you were charged $75 by the provider. You were informed that the services would not be covered by the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe physician services rendered to you on October 1, 2019.Your complaint about the provider 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve140 home health aide visits for the enrollee.You asked the Plan to pre-approvethe visits. You say that this is medically necessary.The Plan denied your request. The Plan says there is no need for skilled services at this time.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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the enrollee does not meet criteria for coverage of the requested HH aide visits. The enrollee does not currently have any skilled nursing needs or skilled therapy needs. The home health aide services are not reasonable and necessary to the treatment of the enrollee's illness or injury by the skilled professional staff. The enrollee's needs are custodial in nature.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 visits have not been met.Therefore, we decided that the Plan does not have to pre-approve140 home health aide visits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you have lost mobility and it is difficult to bathe. You say that you fear for your safety and need the bath chair to improve your quality of life.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Azacitidine for the enrollee.
You asked the Plan to pre-approve Azacitidine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that routine costs for clinical trials is the responsibility of the original Medicare contractor and not the managed care plan. We looked at the file and Medicare rules. Review of the file shows that the enrollee is in a clinical trial. Based on this information, we decided that Medicare rules for coverage of Azacitidine have not been met. Therefore, we decided that the Plan does not have to pre-approve Azacitidine for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve needle electromyography and nerve conduction studies.
You asked the Plan to pre-approve these services. You say that you are in extreme pain. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that needle electromyography and nerve conduction studies are covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you had a normal neurological examination. You have been referred to a neurologist for further evaluation. There is no information in the documentation to support the need for nerve conduction testing. You do not meet the criteria for coverage of the requested services and they are not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve needle electromyography and nerve conduction studies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the audiometric services provided on April 15, 2019
You asked the Plan to pay for the audiometric services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 has network providers
available who can provide the items/services at issue in this appeal. 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 audiometric services provided on April 15,
2019 bythe out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on August 22, 2019.You asked the Plan to waive the copayment forthe office visit. You say that he had been seeing the nurse practitioner. You say that you have been paying $35 instead of $5.The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment per specialist visit. Covered services include services performed by a PCP, specialist, physician assistant or nurse practitioner.The enrollee has been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was provided in a specialist's office. 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 copayment forthe office visit provided on August 22, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 21, 2019 by an out of network provider.
You asked the Plan to pay for the outpatient mental health services. You say that the provider goes to the facility when services are requested and often services are rendered prior to verifying the member's insurance. The Plan denied your request. The Plan says the services provided to the member were not authorized.
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 medical services provided on March 21, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on June 28, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee on June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for subsequent nursing facility care provided on March 17, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says participating providers must be used when available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 physician's services.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 physician's services for subsequent nursing facility care provided on March 17, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home ventilator rental provided on September 19, 2019.
You asked the Plan to pay for the home ventilator, any type, used with non-invasive interface (E0466). You say that you needed the home ventilator. The Plan denied your request. The Plan says criteria for the home ventilator was not met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator, any type, used with non-invasive interface (E0466). Our physician reviewer found coverage criteria for a home ventilator are not met. The enrollee was treated with bi-level positive airway pressure device (BiPAP) and improved, and notes indicate discharge on BiPAP. A ventilator was prescribed in June. There are no medical records supporting the need for a ventilator. There is no evidence for failure of BiPAP, and no compliance data on BiPAP or ventilator use. It is unclear whether the enrollee has chronic obstructive pulmonary disease as there was no pulmonary function testing. Medicare does not cover a home ventilator when used as BiPAP. A home ventilator is considered not medically necessary, and the denial is upheld. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator, any type, used with non-invasive interface (E0466) have not been met. Therefore, we decided that the Plan does not have to pay for the home ventilator rental provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complex motion x-ray (76102) and the occlusal orthotic appliance (D7880) provided from July 17, 2019 to July 23, 2019.You asked the Plan to pay forthe dental services. You say that you were given misinformation by a sales agent. You also say that you were advised that the coverage would be similar to a previous plan that you had.The Plan denied your request. The Plan says the occlusal orthotic appliance is not covered services. The Plan also says that the complex motion x-ray was performed in association with the excluded procedure therefore it is also not a covered service.The Plan must follow Medicare rulesThe rules say that oral occlusal appliances used to treat TMJ disorders are considered to be dental devices and will be denied as non-covered. The rules also say that whether such services as the administration of anesthesia, diagnostic x-rays, and other related procedures are covered depends upon whether the primary procedure being performed by the dentist is itself covered.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occlusal orthotic appliance and x-rays have not been met. Specifically, the occlusal orthotic appliance is excluded from Medicare coverage. The x-rays at issue in this case were provided to determine the need for re-positioning of the occlusal orthotic during the orthotic appliance therapy. This means that the x-rays 
are related to the non-covered occlusal orthotic treatment (primary procedure) and are also non-covered under Medicare rules. Therefore, we decided that the Plan does not have to pay forthe complex motion x-ray (76102) and the occlusal orthotic appliance (D7880) provided from July 17, 2019 to July 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 13, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not have to pay for the emergency room visit because your father was not given pain medicine and there was no oral surgeon in the emergency room. 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 $90 copayment for each visit. The enrollee has been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows the enrollee was evaluated and had laboratory work done during the emergency room visit.
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 copayment for the emergency room visit provided on August 13, 2019.
Your complaint about the enrollee's mistreatment in the emergency room 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 22, 2019 by an out of network provider.
You asked the Plan to pay for the office visit (99214). You say that you were not aware that this is a provider specific plan. The Plan denied your request. The Plan says with limited exceptions, you must use network providers to get your medical care and 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 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 medical services provided on October 22, 2019 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the monthly follow up, assessment, and medication review services provided on June 20, 2019 to July 16, 2019 by the out of network provider.
You asked the Plan to pay for the monthly follow up, assessment, and medication review. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 has network providers available who can provide the items/services at issue in this appeal. 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 monthly follow up, assessment, and medication review services provided on June 20, 2019 to July 16, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections provided on July 2, 2019 to September 10, 2019 by out of network provider.You asked the Plan to pay for injections. You say that these services were covered under the member's own plan. You say that provider understands that prior authorization is required going forward.The Plan denied your request. The Plan says prior authorization was not obtained 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 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 has network providers available who can provide the items/services at issue in this appeal. 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 injections provided on July 2, 2019 to September 10, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the folding wheeled walker provided on August 18, 2019.
You asked the Plan to waive the deductible for the folding wheeled walker. You say that your physician ordered the walker but you did not want the walker. The Plan denied your request. The Plan says you have a $500 deductible and the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 deductible for all covered services. The item or service you asked the Plan to waive the coinsurance for falls within the benefit category durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible for covered medical services before the Plan will begin to pay their share. This cost sharing is a contractual obligation that had not been met at the time the folding wheeled walker was received on August 18, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the folding wheeled walker provided on August 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 19, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 27, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you think this is billed incorrectly. You say that you will not pay for this. The Plan denied your request. The Plan says the correct copayment has been applied to the service that was provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for outpatient diagnostic tests/diagnostic radiology services. The enrollee has been asked to pay $25.76 which is less than your copayment amount of $250 for an ultrasound. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology services 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 copayment for an ultrasound provided on August 27, 2019.