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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 7, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be charged the $90 copayment because you needed to be seen at the emergency room so soon after being discharged from the hospital. 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 $90 copayment per visit for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room visit.
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 emergency room visit provided on December 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyoscyamine sulfate.
You asked the Plan to pre-approve Hyoscyamine sulfate. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hyoscyamine sulfate.
Benefits for Hyoscyamine sulfate 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 11, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physician's services provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are no venous stasis ulcers, and prior ulcers have healed.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not indicate the enrollee has any significant proximal lymphedema. There are no unique characteristics supporting this device above a standard. The records do not indicate a trial period of reasonable duration with a standard pump has been implemented.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 22,
2019 to December 21, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from October 4, 2019
to March 16, 2020. The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing services provided from November 22, 2019 to
December 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307) provided to the enrollee on December 12, 2018.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 80307 (1 unit) remains not supported, as the documentation submitted did not include a lab order for presumptive screening.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 80307 is "Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; byinstrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found after a review of the documentation submitted, no order was found submitted for this code. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307) provided to the enrollee on December 12, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services cannot be
verified.
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 documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the
drug testing services provided on September 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hip x-ray rendered to you on January 15, 2020.
You asked the Plan to waive the copayment for these services. You say that you didn't know there was a copayment. 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 $60 copayment for in-network Medicare-covered x-rays and ultrasounds.
Review of the file shows that you received a hip x-ray on January 15, 2020. Per the contract with the Plan, there is a $60 copayment for in-network Medicare-covered x-rays and ultrasounds. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $46.41. Given that the allowed amount was less than the $60 copayment, you have been asked to pay $46.41 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the hip x-ray rendered to you on January 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amino acid therapy.
You asked the Plan to pre-approve the amino acid therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says amino acid therapy is 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 amino acid therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found some studies have shown mild motor benefit with Mucuna pruriens (cowhage, velvet bean), which contain levodopa, and Vicia faba (broad or fava bean) may have short-term benefits.However, additional studies are needed.Vitamin E and coenzyme Q10 have not been shown to have a neuroprotective effect in Parkinson disease, and they are not currently recommended as dietary supplements for this condition. 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 amino acid therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve amino acid therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic office visits (99201) provided from February 18, 2019 to March 8, 2019.
You asked the Plan to pay for chiropractic office visits. You say that you were told these services would be covered. The Plan denied your request. The Plan says these services are excluded from coverage by Medicare and the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic office visits (99201) provided from February 18, 2019 to March 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer with compressor provided on November 25,
2019 by an out of network provider.
You asked the Plan to pay for the nebulizer with compressor. You say that the Plan should pay this claim. The
Plan denied your request. The Plan says the services 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 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 nebulizer with compressor provided on
November 25, 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 chiropractic manipulative treatment (98940), the functional outcome assessment (G8539), the pain assessment (G8730), and the functional outcome assessment (G8942) rendered by the out of network (OON) provider on August 15, 2019 and August 23, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the enrollee changed their insurance and did not notify your office accordingly. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 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 the chiropractic manipulative treatment (98940), the functional outcome assessment (G8539), the pain assessment (G8730), and the functional outcome assessment (G8942) rendered by the out of network (OON) provider on August 15, 2019 and August 23, 2019.
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 the shower chair was requested for you because of an upcoming surgery you have scheduled. The surgery is for severe foot pain and dysfunction of your tendon and bone. You say it will require a complete foot reconstruction and your Doctor has advised you that you should plan to be completely off your foot for up to seven months. You stated that without the shower chair, it will be impossible for you to shower safely. You say that your weakness is increasing and your balance is worsening and you need the security of the chair to avoid falling. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on November 7, 2019.
You asked the Plan to pay for the dental services. You say that you have been paying for the dental benefit. The Plan denied your request. The Plan says you only have non-routine dental benefits. The Plan says that routine dental benefits are available for an additional premium through the dental rider. The Plan also says that the dental rider was not active at the time that you received these services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that 2019 Annual Notice of Changes was mailed out in August 2018 and explains that preventative dental services were included in 2018, but in 2019 they are not. Additionally, the record shows that you were not enrolled in the Dental Benefit Rider at the time you received the services. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) and knee orthosis with
suspension sleeve rendered on December 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an LSO and knee orthosis 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 pay for these services. Our reviewer says that the
services were not medically necessary. Our physician reviewer found the enrollee had complaints of lower
back and chronic knee pain. The available documentation in the case file does not support that the requested
lumbar-sacral orthosis was medically reasonable and necessary for the enrollee. A physical examination of the
back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been
met. The documentation does not support that the lumbar-sacral orthosis is being prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible physical examination of
the back.
The documentation in the case file does not support that the requested knee orthoses with sleeves were
medically reasonable and necessary for the enrollee. 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.
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 pay for the lumbar-sacral orthosis (LSO) and knee orthosis with suspension sleeve rendered on
December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 24, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnoses listed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided on December 5, 2019 to December 7, 2019.
You asked the Plan to waive the copayment for the emergency room services. 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 emergency room services on the dates of service at issue in this appeal. The Plan states the correct copayment 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 $90 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows you received emergency room services from December 5, 2019 to December 7, 2019. You have been asked to pay a $90 copayment for the emergency room services. The emergency room services fall within the Emergency 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 emergency room services provided on December 5, 2019 to December 7, 2019.