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

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on August 17, 2020.You asked the Plan to waive the copayment forthe ambulance ride. You say that you should not be responsible for the second ambulance ride because you did not need it. 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 $300 copayment for each Medicare covered one-way trip via ground ambulance. You have been asked to pay a $300 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The medical record shows you received non-emergent transport for patient safety.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 fortheambulance ride provided on August 17, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided on June 19, 2020, and June 26, 2020.
You asked the Plan to waive the copayments for wound debridement. You say that you were told that you would only owe a specialist copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received wound debridement on June 19, 2020, at an outpatient hospital facility. Wound debridement is considered and outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. You received wound debridement on June 26, 2020, at an outpatient hospital facility. Wound debridement is considered and outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. The total amount you owe is: $590. You have been asked to pay the total copayment amount of $590 for wound debridement. Wound debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for wound debridement provided on June 19, 2020, and June 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on November 3, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.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 providerin this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 forlab work provided on November 3, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B medication provided on August 10, 2020.You asked the Plan to waive the coinsurance forthe Part B medication. You say that you cannot afford this amount. 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $228.24 which is 20% of the allowed amount for the Part B medication. The allowed amount is $1,141.20. ($1,141.20 x20% = $228.24). The Part B medication falls within the "Medicare Part B prescription drugs" 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 obligationyou agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe Part B medication provided on August 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe computed tomography (CT), abdomen and pelvis provided September 24, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you do not feel that responsible for this due to your doctor sent you to the hospital and did not give you any other option for a possible lower cost share.The Plan denied your request. The Plan says the correct copayment was applied per the Evidence of Coverage.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 $100 copay for advanced imaging servicesprovided in an outpatient hospital facility. You have been asked to pay $100 copay for the CT scan. The CT scan 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 forthe computed tomography (CT), abdomen and pelvis provided September 24, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forPart B Drugs (J2710, J1100, J0330, J0690) provided from August 11, 2020, to August 12, 2020.You asked the Plan to waive the coinsurance forthe drugs. You say that the cost-sharing should be waived.The Plan denied your request. The Plan says the correct amount has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B Drugs. You have been asked to pay a 20% coinsurance for the drugs. The drugs fall within the Part B Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forPart B Drugs (J2710, J1100, J0330, J0690) provided from August 11, 2020, to August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays and preventive procedure provided on August 28, 2020.You asked the Plan to pay forthe complete series of intraoral x-rays and preventive procedure. You say that the Plan representative you spoke with did not advise you that you would have to pay for x-rays.The Plan denied your request. The Plan says benefits for the complete series of intraoral x-rays had been satisfied and the frequency limitation had been exceeded. The Plan also says that the preventive procedure is not covered.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. The contract also says that full mouth or panoramic x-rays are limited to one procedure per calendar year. The record shows that you received a panoramic x-ray on August 18, 2020 and your full mouth or panoramic x-rays benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays and preventive procedure provided on August 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgical services on February 28, 2020.You asked the Plan to waive the copayment forthese services. You say that you shouldn't have needed the second surgery.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 $225 copayment for each Medicare-covered outpatient hospital facility visit. Review of the file shows that you received outpatient surgical services on February 28, 2020. You have been asked to pay a $225 copayment for these services. These services fall within the Medicare-covered outpatient hospital facility 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. Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient surgical services on February 28, 2020. Your complaint about yourphysician after the first surgery 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided.

You asked the Plan to pay for the dental service. You say that you understand that this service is only covered once every 3 plan years. You say that this was an emergency. You also say that you have a new contract each year.The Plan denied your request. The Plan says 1 panoramic x-ray is covered every 3 plan years. The Plan also says that the frequency limit for this service has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 panoramic x-ray every 3 plan years has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received.Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound provided on September 2, 2020.You asked the Plan to waive the copayment forthe ultrasound. You say that you were told a doctor copayment was $20.The Plan deniedyour request. The Plan says you were charged this copayment 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 $25 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $25 copayment for the ultrasound. the ultrasound falls within the Outpatient Diagnostic Tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Thiscost 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 forthe ultrasound provided on September 2, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy for prostate adenocarcinoma (CPT Code 77387 x28), (G6002 x28) and (77525 x28).
You asked the Plan to pre-approve the radiation therapy. You say that the enrollee needs radiation therapy for prostate adenocarcinoma. The Plan denied your request. The Plan says there is no current research showing that the enrollee's type of cancer responds better to the requested type of treatment than the type of treatment the Plan can approve. The Plan states this type of treatment is called intensity-modulated radiation therapy (IMRT) and would be approved if requested.
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 radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found per NCCN radiation compendia proton beam radiation is not a covered indication for prostate cancer. 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 radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy for prostate adenocarcinoma (CPT Code 77387 x28), (G6002 x28) and (77525 x28).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0651) provided.

You asked the Plan to pay for the orthosis. You say that you have attached all pertinent documents. The medical records and doctor's order clearly demonstrate medical necessity for the devices prescribed.The Plan denied your request. The Plan says evidence of misrepresented services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. the delivery ticket submitted did not include the carrier's tracking number. The proof of delivery dd not include an order number or details to corroborate the delivery ticket submitted and the proof of delivery is not itemized to indicate the specific supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0651) provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe DecisionDx-Melanoma testing provided on September 11, 2020.You asked the Plan to pay forthe DecisionDx-Melanoma testing. You say that the DecisionDx-Melanoma testing provided on September 11, 2020 was medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the provided DecisionDx-Melanoma testing provided on September 11, 2020.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 todetermine if the Plan was correct in denying the request to pay for the DecisionDx-Melanoma testing. Our reviewer says that the enrollee does not meet criteria for the provided DecisionDx-Melanoma testing provided on September 11, 2020. Our physician reviewer found the enrollee has no documentation of clinical node status and has a T1a tumor without adverse features. The service is not reasonable or medically necessary.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 DecisionDx-Melanoma testinghave not been met.Therefore, we decided that the Plan does not have to pay forthe DecisionDx-Melanoma testing provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea power wheelchair and accessories.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere needs to be information that shows that the wheelchair is able to be safely operated.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you have a personal mobility deficit but the documentation is not clear that it impairs participation in MRADLs. The documentationindicates memory deficits and a history of seizures therefore it is not clear that you could operate the requested wheelchair. The 11/9/20 functional mobility and wheelchair assessment is not signed and it is unclear if this was completed by a licensed/certified medical professional. As the documentation does not support the need for the power wheelchair the swingaway, retractable, or removable hardware (E1028) and power seating system are not medically necessary.We looked at this physician's review, thefile, 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 Plandoes not haveto pre-approvea power wheelchair and accessories
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe group 3 power wheelchair with multiple power options (K0861).You asked the Plan to pre-approvethe group 3 power wheelchair. You say that you would like reconsideration because this wheelchair is medically necessary.The Plan denied your request. The Plan says you do not have a need for a power tilt and recline seating system and the group 3 power wheelchair is not medically necessary.The Plan follows Medicare rules. Medicare rules say that 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 group 3 power wheelchair. Our reviewer says that you do not meet the coverage criteria for a power tilt and recline seating system. You are not at high risk for development of a pressure ulcer and he is able to perform a functional weight shift. You do not utilize intermittent catheterization forbladder management. You do not use a ventilator. Our physician reviewer found You do not need to operate 3 or more powered seating actuators through the drive control, a separate display,other electronic devices, or an attendant control. 
Your strength andfunction are sufficient to control any power options through their own switches.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 group 3 power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvethe group 3 power wheelchair with multiple power options (K0861).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services providedon September 29, 2020.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. Thecontract 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 servicesat 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 nurse practitioner services provided on September 29, 2020