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

We decided that the Plan does not have to pay for home infusion products provided on July 17, 2019.
You asked the Plan to pay for the home infusion products. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain 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 items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for home infusion products provided on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for image guided radiation therapy provided on July 31, 2019.
You asked the Plan to pay for the image guided radiation therapy. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain 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 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 image guided radiation therapy provided on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal mucosal grafting, multiple reconstructions of the jaw, and multiple moderate sedation services.
You asked the Plan to pre-approve the periodontal mucosal grafting, multiple reconstructions of the jaw, and multiple moderate sedation services. You say that your existing mandibular defect is directly related to treatment of your cancer. You also say that the bony defect of your mandible requires surgical intervention to restore your teeth to pre chemotherapy form and function. The Plan denied your request. The Plan says services provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth is an exclusion under Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. Although the reconstruction of the jaw is a service that is treating a medical condition, the primary purpose of this service is to provide replacement of the missing teeth. Likewise, the gum grafting is treatment/replacement of the structures supporting the teeth. For this reason, the services fall within the Medicare definition of dental care and are excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve periodontal mucosal grafting, multiple reconstructions of the jaw, and multiple moderate sedation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided on August 23, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pressure mattress provided from January 17, 2019 to July 17, 2019.
You asked the Plan to waive the coinsurance for the pressure mattress. You say that you do not agree with the charges. You say no one ever told you there would be a cost-share for these services. 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 in-network Medicare-covered equipment and supplies. You have been asked to pay $130 which is 20% of the allowed amount for the pressure mattress for each date of service. The allowed amount is $650. ($650 x 20% = $130). ($130 x 7 = $910). The pressure mattress falls within the in-network Medicare-covered equipment 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 coinsurance for the pressure mattress provided January 17, 2019 to July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, the lumbar-sacral
orthosis provided on August 9, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397), the lumbar-sacral
orthosis (L0648). You say that the orthoses were medically necessary. The Plan denied your request. The Plan
says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and
suspension sleeve, the lumbar-sacral orthosis provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on August 16, 2019 to August 27, 2019 by an out of network provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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 chiropractic services provided on August 16, 2019 to August 27, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the physician services and the laboratory work provided on September 3, 2019.
You asked the Plan to waive the coinsurance for the physician services and the laboratory work. You say that you were not aware the provider was out-of-network. 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% of the Medicare-allowed amount for out-of-network primary care provider visits for Medicare-covered services and 50% of the allowed amount for services in all settings for each out-of-network Medicare-covered laboratory test. You have been asked to pay $259.67 which is 50% of the allowed amount for the physician services. The allowed amount is $519.34. ($519.34 x 50% = $259.67). The physician services fall within the "Physician/
Practitioner services, including doctor's office visits" benefit category.
You have been asked to pay $6.01 which is 50% of the allowed amount for the laboratory work. The allowed amount is $12.02. ($12.02 x 50% = $6.01). The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the provider is out-of-network.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that the clinical information supports the need for an inpatient psychiatric hospital admission. The Plan denied your request. The Plan says there is no evidence that the enrollee's treatment needs could not be met at a less restrictive, outpatient level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee does not appear to require inpatient mental health treatment as he is not a danger to himself or others and is cooperative and compliant. It does not appear that active treatment is taking place. It does not appear that the services are reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. The enrollee was not shown to be a danger to himself or others, but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for oxygen concentrator, single delivery port,
capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT Code E1390)
provided on September 18, 2019.
You asked the Plan to waive the copayment for the oxygen concentrator. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received an on September 18, 2019. You are asked to pay a $20 copayment
for the DME. 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 oxygen concentrator, single delivery port,
capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (CPT Code E1390)
provided on September 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided September 12, 2019.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you cannot afford the charges. 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 $300 copayment for diagnostic radiology services in an outpatient department of a hospital. You have been asked to pay a $300 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 myocardial perfusion imaging provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, and knee orthoses provided by
Contracting Services of America on August 5, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0648), and knee orthoses (L1833). You say that the
Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not
include an itemized shipping/billing invoice to indicate the specific supplies or proof of delivery.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The USPS proof of delivery has a delivery date of November 29, 2019 and there is no detailed
shipping invoice. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, and
knee orthoses provided on August 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical spine fusion.
You asked the Plan to pre-approve the fusion. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 fusion. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented spinal instability, fracture, or lesion. There is no severe neurologic deficit. More conservative measures are needed. Surgery is not needed. 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 fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical spine fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of Benralizumab (J0517) provided from January 4, 2019 through June 21, 2019.
You asked the Plan to waive the coinsurance for an injection of Benralizumab. You say that you should not be assessed a coinsurance for the medications that were administered. You say that the claim was processed incorrectly and you believe that this error and the length of time it took to reprocess and pay on the claims should entitle you to only have to pay the outpatient hospital services copayment. The Plan denied your request. The Plan says Medicare Part B prescriptions drugs have a 20% coinsurance.
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 Medicare Part B prescriptions. You have been asked to pay a 20% coinsurance for an injection of Benralizumab. This service falls within Medicare Part B prescriptions benefit category. There were 4 dates of service recorded (January 4, 2019, March 1, 2019, April 26, 2019, and June 21, 2019). On 2 dates of service you had $0 payments due to your previous payments. Here are the amounts per dates of service recorded: $318.43 + $0 + $0 + $1,051.28 = $1,369.71. 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 for an injection of Benralizumab (J0517) provided from January 4, 2019 through June 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy procedure provided on August 29, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that this procedure should have been billed as a specialist visit and not an outpatient procedure. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $325 copayment for in-network outpatient surgery provided at an outpatient hospital facility. The biopsy procedure performed is considered to be a surgical service, and this practice is an outpatient hospital facility. You have been asked to pay $325 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including 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 copayment for a breast biopsy procedure provided on August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays provided on September 17, 2019.
You asked the Plan to waive the copayment for the x-rays. You say that your copayment should cover the x-ray
and you should not be charged extra. 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 $35
copayment per day, per provider, for in-network Medicare-covered x-ray 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 $35 copayment for
the x-ray.
You have been asked to pay a $25.87 copayment for the x-rays. The x-rays fall 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 x-rays provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided on August 29, 2019 by out of network provider.  You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 rest home visit services provided on August 29, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services provided on
August 14, 2019.
You asked the Plan to waive the copayment for the physician's services. You say that you requested and received a yearly routine eye exam and you assumed that is what you received. You say your insurance covers this without a copayment. The Plan denied your request. The Plan says the correct cost-share was applied to the claim.
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 $40 copayment for vision care. You have been asked to pay $40 copayment for the physician's services. The physician's services falls within the vision care benefit category for a Medicare-covered eye exams. The file shows that the physician performed services for age-related macular degeneration, which is a Medicare-covered exam for diseases or conditions of the eye. 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 physician's services provided on
August 14, 2019.