Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided May 3 to May 18, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you already paid the hospital $925.71 and that should cover the cost. The Plan denied your request. The Plan says the $925.71 was for physician services provided prior to the $1,000 deductible being met. The physician services are a separate claim from the inpatient hospital services.
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 $675 per admission for Inpatient Hospital Care. You have been asked to pay $675 per admission for the inpatient hospital services. the Inpatient hospital services fall 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 waive the copayment for inpatient hospital services provided May 3 to May 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) services rendered to you from December 10, 2019 to December 31, 2019.You asked the Plan to waive the copayments for these services. You say that the copayments are a financial hardship.The Plan denied your request. The Plan says the copayments were 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 $15 copayment for each Medicare-covered physical therapy visit. Review of the file shows that you had eight PT visits from December 10, 2019 to December 31, 2019. You have been asked to pay a $15 copayment per visit for these services, for a total of $120. These services fall within the Medicare-covered physical therapy visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy (PT) services rendered to you from December 10, 2019 to December 31, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecrowns (D2751) for tooth #'s 10 & 11.You asked the Plan to pre-approvethe crowns. You say that you got crowns and they all fell out of your mouth. You also say that you would like the crowns replaced.The Plan denied your request. The Plan says this service is allowed one time every 60 months. The Plan alsosays that their records show that you had this service done less than 60 months ago.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 rulesapply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are limited to once per tooth per 60 months. The record shows that you received crowns on tooth #'s 10 & 11 on August 16, 2017 and your crowns benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approvecrowns (D2751) for tooth #'s 10 & 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided September 3, 2019 to September 6, 2019. You asked the Plan to waive the copayment forthe inpatient hospital care. You say that the hospital did not help you and the copayment should be waived.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). Your contract with the Plan clearly says that you must pay a $260 per day copayment for days 1-4 of an inpatient stay.You have been asked to pay a $780 copayment for 3 days of inpatient hospital care. 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 forinpatient hospital care provided September 3, 2019 to September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.You asked the Plan to pre-approvea stair glide. You say that you need the requested stair lift to function as a normal human being. You say that you cannot walk or stand for more than a few minutes. You stated that your multiple diagnosis force you to crawl up the steps in your home. You say that you need the requested equipment to help you find relief and to live a more normal life.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 stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither thePlan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea stair glide.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services provided to the enrollee.
You asked the Plan to pay for home health aide services provided to the enrollee. You say these services should be covered. The Plan denied your request. The Plan says the provider used is not a Medicare participating provider and it not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for Medicare-covered services, a provider must be enrolled in the Medicare program. The Plan contract says that enrollees must use Medicare eligible providers. The provider in question is not eligible to participate in Medicare. Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services provided by to the enrollee from September 1, 2019 to October 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ileostomy medical supplies to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe Ileostomy medical supplies. You say that because you were beingdenied your essential medical supplies you needed to seek a new supplierThe Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contractedproviders require prior-authorization prior to services being rendered.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-approvethe Ileostomy medical supplies to be provided by anout of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services provided July 10, 2019 
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the services should be covered and the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $90 copayment for Emergency Care. The enrollee has been asked to pay a $90 copayment for the Emergency Room Services. The Emergency Room Services fall within the Emergency 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 Emergency Room Services provided July 10, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee from
January 16, 2019 to March 13, 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 not authorization in compliance with the plan's authorization procedures.
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 psychotherapy services provided to the enrollee
from January 16, 2019 to March 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular partial
denture.
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you had to have
a clean mouth due to medical reasons. The Plan denied your request. The Plan says dentures are not covered by
Medicare.
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. Therefore, we decided that the Plan does not have to pre-approve a
maxillary partial denture and a mandibular partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bone replacement graft for ridge preservation.You asked the Plan to pre-approvethe bone replacement graft. You say that the enrollee is unable to eat and is in severe pain.The Plan denied your request. The Plan says this service is not a covered benefit.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.Therefore, we decided that the Plan does not have to pre-approvea bone replacement graft for ridge preservation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve weight management classes
You asked the Plan to pre-approve the classes. You say that you are considered obese. The Plan denied your request. The Plan says this is not a covered benfeit.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Additionally, HCPCS S9449 represents a non-covered code. Therefore, we decided that the Plan does not have to pre-approve weight management classes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on October 25, 2019.You asked the Plan to waive the copayment forthese services. You say that you only had a regular office visit with your doctor.The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for each Medicare-covered outpatient hospital visit. Review of the file shows that you received outpatient hospital services on October 25, 2019. Per your contract with the Plan, there is a $325 copayment for each Medicare-covered outpatient hospital visit. This cost sharing is a contractual obligation you agreed to pay when you enrolled in thePlan. However, the Medicare allowed amount for these services was $97.39. Given that the allowed amount was less than the $325 copayment, you have been asked to pay $97.39 for these services.Therefore, we decided that the Plan does not have to waive thecopayment forthe outpatient hospital services rendered to you on October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to a crown
(D2954) and a crown (D2791) for tooth # 18. You asked the Plan to pre-approve the dental services. You say that your current crown is cracked. You say that pieces keep falling out. You also say that you cannot chew because the crown will completely fall off. The Plan denied your request. The Plan says crowns, bridges, inlay/only and periodontal work may not be provided more often than once every 5 years. The Plan also says that the benefit limit has been exhausted. 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 and the requested services are listed as covered, the benefit limit has been exhausted. The record shows the Plan paid for a crown for tooth # 18 that you received on November 10, 2017. Therefore, we decided that the Plan does not have to pre-approve a prefabricated post and core in addition to a crown (D2954) and a crown (D2791) for tooth # 18.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 to October 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you were not aware you needed prior authorization. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 medical services provided on September 27, 2019 to October 4, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre CGM system.
You asked the Plan to pre-approve a CGM. You say that you take 3 injections a day and check sugar at least 6 times a day. The Plan denied your request. The Plan says there is no documentation that you check glucose or inject insulin 3 times a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The medical record shows you are insulin injecting once an evening and there is no log of testing. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment.
You asked the Plan to pre-approve these services. You say that you are requesting chiropractic care for back pain as you have to take pain medication in order to walk. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage of chiropractic care as there is no evidence of a subluxation of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 these services. Our reviewer says that you do not meet criteria for coverage of chiropractic manipulative treatment. Our physician reviewer found that there are no x-rays revealing evidence of a subluxation of the spine. The submitted whole body bone scan, dated December 10, 2019, reveals vertebral pathological fracture; however, does not reveal evidence of a subluxation of the spine. Additionally, the office visit notes of December 26, 2019 and the submitted urological progress note of January 8, 2020 do not reveal a subluxation of the spine per Medicare guidelines. Thus, chiropractic treatment is not supported or allowed. In addition, your medical history indicates conditions for which chiropractic manipulation would be an inappropriate therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Self-Administered Drugs (A9270) provided September 26 and September 27, 2019.
You asked the Plan to pay for the Self-Administered drugs. You say that you had these drugs at home and should not have to pay for them. The Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are generally not eligible for coverage under the Part B Medical Benefit.
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 Self-Administered Drugs (A9270) provided September 26 and September 27, 2019.
Benefits for the Self-Administered drugs 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for Outpatient Mental Health services (90834) to be provided.You asked the Plan to reduce the copayment forthe outpatient mental health services. You say that all other specialist visits have a $30 copayment and outpatient mental health visits should be the same.ThePlan denied your request. The Plan says the contract stipulates a $40 copayment for in-network outpatient mental health visits, and a $50 copayment for outpatient mental health visits provided out-of-network.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 $40 copayment for in-network Outpatient Mental Health Care. You have been asked to pay a $40 copayment for in-network outpatient mental health visits. 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 forOutpatient Mental Health services (90834) to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmology services with an in-network exception to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the ophthalmology services. You say that you would like to see this provider for a second opinion and you understand the plan will be responsible for only partial payment of the cost and you will be responsible for the other half.The Plan denied your request. The Plan says as a member of the plan you can receive care from either a network provider or an out-of-network provider. If you use an out of network provider, your share of costs for covered services may be higher.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 the ophthalmology services with an in-network exception to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrocardiogram (EKG) rendered on August 9, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 93010 is not supported.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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.We find that CPTcode 93010 is not supported in the medical record. Specifically, the records do not show that an EKG was performed for the billed date of service. The records show the EKG was performed on August 10, 2019. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe electrocardiogram (EKG) rendered on August 9, 2019.