Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel of 22 or more drug classes provided on April 26, 2019.
You asked the Plan to pay for the definitive drug panel. You say that the documentation supports the payment of this claim. The Plan denied your request. The Plan says the order does not specify the drugs to be tested on the panel.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordering by a treating provider. In this case, the requisition form is not sufficiently detailed to support the intent of a panel of 22 or more drug classes. Therefore, we decided that the Plan does not have to pay for the definitive drug testing panel of 22 or more drug classes provided on April 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2018 by out of network provider
You asked the Plan to pay for nerve conduction studies (95913) and needle electromyography (95886). You say that the services were medically necessary. The Plan denied your request. The Plan says you did not get 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 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 on August 14, 2018 by out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the custom orthotics were prescribed to improve your gait pattern, reduce lower back and leg pain, level and stabilize your hips and improve your overall mobility. You say that the Plan's denial was based on a lack of adequate information.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220), and the porcelain crown (D2740) provided on September 24, 2019.
You asked the Plan to pay for the dental services. You say that you were advised the services would cost you $896. You say that you are a senior on a single income. You say that you planned on paying $396, not $896. The Plan denied your request. The Plan says the periapical x-ray and porcelain crown are not listed as covered services.
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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220), and the porcelain crown (D2740) provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation and two follow up podiatry visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a consultation and follow up visits. You say that this should be a covered service and understands that your podiatrist of choice is not in-network. You feel it should be okay as you are a type 2 diabetic and you have been seeing him for years and you only feel comfortable going with this doctor. The Plan denied your request. The Plan says requests to out-of-network providers can be approved for emergency or urgent care. It can also be approved when the service is not offered in the network. This provider is not in the network. The care you need is not an emergency. It is not needed urgently. It is offered in the network. The Plan has podiatry providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a consultation and two follow up podiatry visits to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 15, 2019.
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 the documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to 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 drug testing services provided to the enrollee on April 15, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on November 4, 2019.You asked the Plan to waive the copayment for the laboratory services. You say that you thought you were supposed to have a $0 copayment.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 $45 copayment for laboratory services at an in-network outpatient hospital. You have been asked to pay a $45 copayment for the laboratory services. The laboratory services 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 laboratory services provided on November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab tests provided on May 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab tests. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization/referral was 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 outpatient lab tests provided on May 31, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the implant (D6010), the free soft tissue graft
procedure (D4277), and the inhalation of nitrous oxide (D9230) provided from May 13, 2019 to September 3,
2019.
You asked the Plan to reimburse you for the dental services. You say that in September 2019 you discovered
that the lower bridge had failed. You say that is why you needed to have these services. You also say that you
are on a fixed income. The Plan denied your request. The Plan says the services that you received are not
covered services.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to reimburse you 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. Therefore, we decided that the Plan does not have to reimburse you for the
implant (D6010), the free soft tissue graft procedure (D4277), and the inhalation of nitrous oxide (D9230)
provided from May 13, 2019 to September 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for upgraded airline ticket fee for wheelchair accommodation and wheelchair transport provided on October 7, 2019.You asked the Plan to pay for the upgraded airline ticket and wheelchair transportation fees. You say that you sustained an injury while in Hawaii and had to upgrade to a first class ticket because you needed a full reclining seat and to keep your leg elevated and transportation from the airport to your home.The Plan denied your request. The Plan says the requested services are not a covered benefit under the plan benefits under any normal circumstance.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.  The health plan contract on page 28 specifically says ambulance services exclusions: transportation by car, taxi, bus, gurney van, wheelchair van, and any other types of transportation (other than a licensed ambulance or psychiatric transport van, even if it is the only way to travel to a plan provider.The services you have asked the Plan to pay for are wheelchair van transport services.Therefore, we decided that the Plan does not have to pay for upgraded airline ticket fee for wheelchair accommodation and wheelchair transport provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing care provided on October 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing care. You say that you would like reconsideration for payment.The Plan denied your request. The Plan says no prior authorization was 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 skilled nursing care provided on October 16, 2019 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine tablets (J8499).You asked the Plan to pre-approve Cyclobenzaprine tablets. You say that the enrollee has been taking this medication and should continue.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Cyclobenzaprine tablets (J8499).Benefits for Cyclobenzaprine tablets 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva Respimat for the enrollee.You asked the Plan to pre-approve this drug. You say that the enrollee has tried and failed other medications.The Plan denied your request. The Plan says that drug coverage is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Spiriva Respimat for the enrollee.Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided you by an out-of-network provider on May 20, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available 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 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 you by an out-of-network provider on May 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ear wax removal provided on September 9, 2019.
You asked the Plan to waive the copayment for the ear wax removal. You say that you had an outpatient procedure to have earwax removed. You say that you did not have a surgical procedure or minor surgery. 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). Your contract with the Plan clearly says that you must pay a $300 copayment for each Medicare-covered outpatient surgery service. You have been asked to pay $106.93, which is less than the standard $300 copayment for the ear wax removal. The ear wax removal falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The ear wax removal is considered a surgical procedure. 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 ear wax removal provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214), and an electrocardiogram, (ECG) (93000) provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit and an ECG. You say that you are seeking a review and requesting payment for the services rendered. Services were performed based on the patient's health condition. Services were necessary and the provider was unaware that the service required authorization.The Plan denied your request. The Plan says the provider is a non-network provider who does not work with the member's health plan, and the member self-directed for care. The member's primary care provider did not refer for services. The health 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, had 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 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 an office visit (99214), and an electrocardiogram, (ECG) (93000) provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) service.You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an LTACH admission, the services can be provided at a lower level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on August 24, 2019.You asked the Plan to waive the copayment for the urgent care visit. You say that you paid $35. You say that you thought that's all you owed.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). Your contract with the Plan clearly says that you must pay a $65 copayment for Medicare-covered urgently needed care visits.You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" 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 urgent care visit provided on August 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amlodipine BESYLATE (J8499).
You asked the Plan to pre-approve Amlodipine BESYLATE. You say that you need this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of your Part D prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Amlodipine BESYLATE (J8499).