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

We decided that the Plan does not have to pre-approve a portable oxygen concentrator 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you cannot carry heavy
canisters for a stationary concentrator. The Plan denied your request. The Plan says the record shows your O2
saturation does not meet coverage guidelines.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
We looked at the file and Medicare rules. Documentation provided does not support medical necessity. Based
on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator have not
been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering services provided to the enrollee on September 3, 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 use of 3D-rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, or other tomographic modality with image postprocessing is not covered separately by Medicare if it is contained in the authorized radiologic procedure.
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 76376 is "3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found in order to qualify for reimbursement separately for 3 D rendering and interpretation the necessity for the 3D rendering must be included in the dictation of the radiologist at the time of interpretation. In other words, a statement such as "3D rendering was necessary to optimally visualize the trachea etc." Such a statement is not present in the report thus there is no justification for the additional 3D rendering charge. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for 3D rendering services provided to the enrollee on September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the supplies are medically necessary
because of your medical issue. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEpclusa 400/100mg tablets.You asked the Plan to pre-approvethe Epclusa tablets. You say that this medication is necessary.The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B.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-approveEpclusa 400/100mg tablets.Benefits for the Epclusa tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from July 31, 2019 to August 12, 2019. You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you would like the claim processed according to each of the two plan's benefits. 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 $320 copayment for each day for days 1-5 for Medicare-covered hospital care and $0 copayment for additional Medicare-covered days. You have been asked to pay a $320 copayment for each day for days 1-5 of the inpatient hospital stay. ($320 x 5 = $1,600). The inpatient hospital stay falls within the "Inpatient Hospital 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 reduce the copayment for the inpatient hospital stay provided from July 31, 2019 to August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood pressure monitor/blood pressure monitoring provided on October 28, 2019.
You asked the Plan to pay for a blood pressure monitor/blood pressure monitoring during an ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24 hours.
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 A4670 is automatic bp monitor, dial.
We find that CPT code A4670 is not supported in the medical record. Specifically, the enrollee did not receive a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately payable. Based on this information, we decided that Medicare rules for coverage of a blood pressure monitor/blood pressure monitoring during an ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for a blood pressure monitor/blood pressure monitoring provided on October 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on June 14, 2018.You asked the Plan to pay forthe ambulance services. You say that the ambulance services were medically necessary.The Plan denied your request. The Plan says medical records to support medical necessity were requested but not received.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient'shealth. The Plan follows the same rules. We looked at the file and Medicare rules. There are no records to support medical necessity. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forservices provided on June 14, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from October 6, 2019 through October 9, 2019.
You asked the Plan to waive the copayment for the SNF services. You say that you should not have a copayment because the facility kept you a week longer than they should have. The Plan denied your request. The Plan says that the copayment applies per your 2019 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 a $160 copayment per day for days 21-44 of a benefit period for SNF care. You have been asked to pay a $480 copayment for the SNF services. The SNF services fall within the days 21-44 of a benefit period for SNF 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 skilled nursing facility (SNF) services provided from October 6, 2019 through October 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on October 3, 2019.
You asked the Plan to pay for the colonoscopy. 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. 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 a colonoscopy provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to reduce the cost-sharing charges fora Medicare Part B drug. We decided that the Plan does not have to reduce the cost-sharing charges fora Medicare Part B drug. You asked the Plan to reduce the cost-sharing charges fora Medicare Part B drug. You say that you feel that the charges should be included in the $40 copayment.The Plan says that the claims were processed correctly and you are being charged the correct amount. We decided that the Planhas to reduce the cost-sharing charges fora Medicare Part B drug from $80.92 to $79.62. The Plan contract says that enrollee's must pay 20% coinsurance for Medicare Part B drugs. The plan says you must pay $80.92 for a Medicare Part B drug. However, you cannot be asked to pay more than 20% coinsurance.Therefore, we decided that the Plan has to reduce the cost-sharing charges fora Medicare Part B drugfrom $80.92 to $79.62. We also decided that the Plandoes not have to reduce the cost-sharing charges fora Medicare Part B drug to the amount you requested.  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 a Medicare Part B drug.Thee allowed amount is $398.12 and 20% of that is$79.62. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges fora Medicare Part B drug to the amount you requested. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) purchased August 10, 2019. You asked the Plan to pay for the vision services. You say that you are appealing the denial of your reimbursement of your prescription eyeglasses (frame and lenses) for $94.35. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in network optical provider. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from an in network optical provider. We looked at the file and the Plan's rules. Services received from non-network provides are not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) purchased August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on October 31, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was enrolled in a hospice program.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient services (57410, 49000, 52000, 58210, 45331, 38780)  provided on June 5, 2019 to June 8, 2019.You asked the Plan to pay forthe inpatient services. You say that the services were preauthorized and medically necessary.The Plan denied your request. The Plan says that the plan was not notified of the elective procedure within 24 hours.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 record shows the services at issue in this case were pre-authorized. A letter from the plan dated May 23, 2019 indicates the procedure would be authorized. The letter does not state that the service must be performed within 24 hours.The Evidenceof Coverage does not detail any rule regarding a 24 hour notice for surgical procedures. Therefore, we decided that the Plan has to pay forthe inpatient services (57410, 49000, 52000, 58210, 45331, 38780)  provided on June 5, 2019 to June 8, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay $95 for home health services provided to the enrollee from November 25, 2019 to November 29, 2019. You asked the Plan to pay $95 for this service. You say that this claim should be paid, and the enrollee had prior authorization. The Plan denied your request. The Plan says prior authorization was approved for rendered services; however, Denson Home Health, Inc. is not in-network with the Plan. The claim forms do not have the appropriate home health data to process and pay the claim. The final claim must have the appropriate Type of Bill or 329 to process and pay the claim. The Plan states they accept a submission of a corrected claim to consider services for payment. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Medicare requires providers to submit claims with the appropriate codes and appropriate bill types. The claim submitted required a specific bill type for submission. This claim cannot be paid as billed. The Plan states a corrected claim would be accepted if submitted. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay $95 for home health services provided to the enrollee from November 25, 2019 to November 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for foot surgery provided on April 12, 2019.You asked the Plan to waive the coinsurance for foot surgery. You say that you have never had a hospital bill more than $300. You say that the cost should be reduced or waived.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each covered surgery or observation room service in an in-network outpatient hospital.You have been asked to pay $2,725.94, which is 20% of the allowed amount for the foot surgery. The allowed amount is $13,629.68 (20% of $13,629.68 = $2,725.94). The foot 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 coinsurance for foot surgery provided on April 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on October 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer needs to be billed first.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified an insurance as the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on October 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided from August 16, 2019 to September 7, 2019. You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that the services were medically necessary and it was unclear this was considered a hospital stay. The Plan denied your request. The Plan says the correct cost-sharing was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 per day copayment for days 1 through 6 for Inpatient Care. The enrollee has been asked to pay an $1,800 copayment for 6 days of Inpatient Rehabilitation Services. The inpatient rehabilitation services fall within the Inpatient Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient rehabilitation services provided from August 16, 2019 to September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 29, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 Plandid not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon August 29, 2019.