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

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on February 19, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. 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 20% coinsurance for DME and related supplies. You received DME and related supplies on February 19, 2020. The allowed amount is $477.90 and 20% of that is $95.58. You have been asked to pay the total coinsurance amount of $95.58 for DME and related supplies. DME and related supplies fall within the DME and related 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 DME and related supplies provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Maxillary Partial Denture (D5213).
You asked the Plan to pre-approve the Partial Denture. You say that a new partial denture is medically
necessary. The Plan denied your request. The Plan says the benefit for partial dentures has been exhausted
already.
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. The Plan covers on Maxillary
Partial Denture every five years.
We looked at the file, and Medicare rules. The record shows a Maxillary Partial Denture was already provided
September 30, 2019. Based on this information, we decided that the Plan's rules for coverage of the Partial
Denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a Maxillary
Partial Denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Alprazolam tablet, Losartan tablet, Nitroglycerin tablet, and Pravastatin tablet provided on October 3, 2019 and October 4, 2019.
You asked the Plan to pay for the Alprazolam, Losartan, Nitroglycerin, and Pravastatin. The Plan denied your request. The Plan says these drugs are not covered under your plan. The Plan also says these drugs are self-administered.
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 pay for the Alprazolam tablet, Losartan tablet, Nitroglycerin tablet, and Pravastatin tablet provided on October 3, 2019 and October 4, 2019.
Benefits for the Alprazolam, Losartan, Nitroglycerin, and Pravastatin 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses (V2781) purchased on December 18, 2019.You asked the Plan to pay for the lenses. You say that you do not have any lenses because you asked the provider to remove the lenses and this provider has the new lenses and your old lenses. You would like to use your vision benefit elsewhere to get lenses.The Plan denied your request. The Plan says although you were not satisfied with the service you received from this provider, the lenses were still made and are available to you.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 $200 coverage limit for eyewear every 12 months. Benefit allowance must be used on the same date of service and provide no remaining balance for future use within the same benefit frequency. We looked at the file and the Plan's rules. the lenses were still made and are available to you. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met.Therefore, we decided that the Plan does not have to pay for the progressive lenses (V2781) purchased on December 18, 2019.Your complaint about the provider being condescending and unprofessiona lis 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Orthovisc 15mg/ml syringe.You asked the Plan to pre-approve a tier exception for Orthovisc 15mg/ml syringe. You say that the exception is needed since the medication is not affordable.The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Orthovisc 15mg/ml syringe have not been met. Specifically, the requested drug is covered under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part B Drugs are not subject to tier exceptions.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Orthovisc 15mg/ml syringe.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services (23430, 29823, 29824, 29826) provided on October 2, 2018.
You asked the Plan to pay for surgical assistant services. You say that this should be reprocessed. The Plan denied your request. The Plan says surgical assistant services are not covered when provided by an RNFA.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (23430, 29823, 29824, 29826) provided on October 2, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cataract surgery provided on January 8, 2020.You asked the Plan to reduce the copayment for the cataract surgery. You say that you should only be charged a $150 copayment from the ambulatory surgery center. 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 $200 copayment for each Medicare-covered visit to an ambulatory surgical center. You have been asked to pay a $200 copayment for the cataract surgery. The cataract 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 reduce the copayment for the cataract surgery provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fluoroscopic guidance provided on December 13, 2019.You asked the Plan to waive the copayment for the fluoroscopic guidance. You say that you were advised your copayment was only $45. You say that there was no additional charge for the visit.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 separate office visit copaymentapplies for diagnostic tests and procedures, diagnostic radiology, and therapeutic radiology. You have been asked to pay $58.80, which is less than the $100 copayment for the fluoroscopic guidance. The fluoroscopic guidance falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.Outpatient diagnostic tests are considered a separate service.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 fluoroscopic guidance provided on December 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested admission 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications.
The enrollee had stable vital signs. The enrollee received routine foley catheter care. The enrollee required
minimal assistance to contact guard assistance with functional mobility including walking to 50 feet. The
documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a
skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and
reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are
required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an
inpatient basis, at a SNF level of care.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on November 29, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not Medicare benefits for the diagnoses listed on the claim.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal were requested for screening purposes. Medicare does not cover the tests for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on December 18, 2019.
You asked the Plan to pay for the vaccine. You say that you thought this would be covered. The Plan denied
your request. The Plan says this is not covered under Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that you have been injured or directly exposed to any illness related to the vaccine.
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on December
18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 28, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were unable to be admitted to the hospital because there were no vacant rooms. You say that the copayment should be waived. 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 $85 for each visit to an emergency room. You have been asked to pay an $85 for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER and discharged. 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 ER visit provided on January 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for drug services received on November 20, 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 services were paid at the allowable amount per CMS's Ambulatory Patient Classification (APC) methodology.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for drug services received on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge services (CPT 99239) provided on October 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 99239 is "Hospital discharge day management; more than 30 minutes". We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided do not show that more than 30 minutes of hospital discharge day management services were provided on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the discharge services (CPT 99239) provided on October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Air Purifier (E1399).
You asked the Plan to pre-approve the Air Purifier. You say that the purifier is medically necessary due to breathing trouble. The Plan denied your request. The Plan says air purifiers are not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an Air Purifier (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use (D9630) provided on June 26, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the service is not a covered benefit under the plan.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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use (D9630) provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient physician services provided on December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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. These services were outpatient services. 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 physician services provided on December 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 23, 2019.You asked the Plan to waive the copayment for the office visit. You say that you have no cost for a PCP. You say that the claim should be reprocessed.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 $5 copayment per primary care physician (PCP) visit. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the hip brace provided on October 29, 2019.You asked the Plan to waive the coinsurance for the hip brace. You say that the brace is unwearable. You say that you shouldn't have to pay the coinsurance.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 Medicare covered prosthetic devices. You have been asked to pay $184.92, which is 20% of the allowed amount for the hip brace. The allowed amount is $924.61 (20% x $924.61 = $184.92). The hip brace falls within the "Prosthetic Devices and Related 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 forthe hip brace provided on October 29, 2019.