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

We decided that the Plan does not have to waive the copayment for solid skin barrier (A4362), ostomy belt (A4367), skin barrier liquid per oz (A4369), extended wear ostomy skin barrier (A4407), and ostomy pouch (A4425) provided on February 13, 2020 by the provider.You asked the Plan to waive the copayment for the solid skin barrier, ostomy belt, skin barrier liquid per oz, extended wear ostomy skin barrier, and ostomy pouch. You say that you should not be responsible for the coinsurance since you have never had to pay for the supplies before.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 DME. You have been asked to pay $76.31 for the solid skin barrier, ostomy belt, skin barrier liquid per oz, extended wear ostomy skin barrier, and ostomy pouch. 20% of the total amount for the DME supplied equals $76.31. Solid skin barrier, ostomy belt, skin barrier liquid per oz, extended wear ostomy skin barrier, and ostomy pouch fall within the DME 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 solid skin barrier (A4362), ostomy belt (A4367), skin barrier liquid per oz (A4369), extended wear ostomy skin barrier (A4407), and ostomy pouch (A4425) provided on February 13, 2020 by the provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 18, 2019 to June 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services (98941). You say that you would like reconsideration because a referral is not necessary per state law. The Plan denied your request. The Plan says with limited exceptions, the member must use network providers to get medical care and 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 the medical services provided on February 18, 2019 to June 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve physical therapy visits for the enrollee.You asked the Plan to pre-approve the visits. You say that this is medically necessary.The Plan denied your request. The Plan says that the documentation provided does not appear to establish that the enrollee needs the unique skills of a therapist to improve functioning.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 visits. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found physical therapy is generally accepted as specific and effective for treating gait abnormalities. There is a history of recent fall and there is no evidence that he is effectively performing a home exercise program. Skilled physical therapy is needed for gait training, assistive device use, and to develop a maintenance home exercise program. The enrollee's condition would be expected to deteriorate without the physical therapy being requested.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 visits have been met.Therefore, we decided that the Plan has to pre-approve physical therapy visits for the enrollee.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CardioMEMS.You asked the Plan to pre-approve CardioMEMS. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve CardioMEMS. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a history of obstructive sleep apnea, pulmonary hypertension, obesity, COPD, atrial fibrillation and NYSHA Class III congestive heart failure with preserved ejection fraction (LVEF 55-60%) requiring hospitalization. CardioMEMs device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. The efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. Therefore, the device is still considered experimental or investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have not been met.Therefore, we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206), periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the dental services. You say that you are aware that fluoride varnish was not covered under the dental plan and the patient has paid for it. You state you believe this was only the second prophylaxis and exam for the patient in 2019. The Plan denied your request. The Plan says the services are not covered.
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 enrollee received two of each service prior to this date of service on March 12, 2019 and April 11, 2019. Furthermore, the fluoride varnish is not a covered benefit. Therefore, we decided that the Plan does not have to pay for topical application of fluoride varnish (D1206), periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided to the enrollee on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 20, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 5, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were charged an exorbitant amount for less than a 1/4 mile to the emergency room. 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 $200 copayment for Medicare-covered ambulance services. You pay this amount for each one-way trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from May 17, 2019 through May 23, 2019. You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that the enrollee was admitted on May 17, 2019 and discharged on May 23, 2019. The enrollee was asked to pay a $320 copayment per day from May 17, 2019 through May 21, 2019, days 1-5 of their inpatient stay. There were no copayment charges from May 22, 2019, day 6 of their inpatient hospital care until their day of discharge May 23, 2019. Per the enrollee's contract there is a $320 copayment per day required for days 1-5. 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 hospital care provided to the enrollee from May 17, 2019 through May 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the lower leg x-ray (73590). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the non-contracted provider did not follow the rules of the plan prior to rendering 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 the medical services provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for case presentation, detailed and extensive treatment planning (D9450) and intraoral - complete series of radiographic images (D0210) provided on February 19, 2020.
You asked the Plan to pay for the dental services. You say that you were very specific with the office on what was to be done during the appointment. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay 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. The plan provided payment for the dental comprehensive oral evaluation as that is a covered benefit. The non-covered dental services provided were denied because the services are not covered by Medicare or the Medicare Advantage plan. You had a full mouth of x-rays completed as well as an extensive evaluation assessment. Therefore, we decided that the Plan does not have to pay for case presentation, detailed and extensive treatment planning (D9450) and intraoral - complete series of radiographic images (D0210) provided on February 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the corneal transplant provided on March 13, 2019.
You asked the Plan to waive the copayment for the corneal transplant. You say that an in-network preauthorization was issued for the corneal transplant. You say that you cannot be made responsible. 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 $225 copayment for in-network, Medicare-covered outpatient surgery. You have been asked to pay a $225 copayment for the corneal transplant. The corneal transplant falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that you were charged the in-network rate for the corneal transplant. 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 corneal transplant provided on March 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy pouch and drainage bag provided on January 10, 2020.
You asked the Plan to waive the coinsurance for the ostomy pouch and drainage bag. You say that you were not notified of a change in cost. You say that you shouldn't have to pay the bill. 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 prosthetic devices and medical supplies You have been asked to pay a total of $42.23 for the ostomy pouch and drainage bag.
The ostomy pouch and drainage bag fall 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 for the ostomy pouch and drainage bag provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ophthalmology services (92012 and 92136). You say that you would like reconsideration because the services were medically necessary and rendered in good faith. The Plan denied your request. The Plan says the provider should have verified the member's eligibility, health benefits and obtained authorization prior to the member's visit before providing services to the member as outlined on the member's ID card.
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 October 30, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for collection and application of autologous blood concentrate product (D7921) and bone replacement graft for ridge preservation - per site (D7953) provided on October 17, 2019 by a provider not certified with Medicare.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay 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. The services are not covered per Medicare rules. Furthermore, the provider it not Medicare certified. Therefore, we decided that the Plan does not have to pay for collection and application of autologous blood concentrate product (D7921) and bone replacement graft for ridge preservation - per site (D7953) provided on October 17, 2019 by a provider not certified with Medicare.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 to the enrollee by an out-of-network provider on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar orthosis (L0625) provided to the enrollee on January 21, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. There is no document from the durable medical equipment supplier to indicate what device or supplies were delivered or given to the member for date of service January 21, 2019. There is no proof of delivery slip or a UPS/USPS tracking sheet and no signed physician order or written prescription for each device or supply. Therefore, we decided that the Plan does not have to pay for lumbar orthosis (L0625) provided to the enrollee on January 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from December 5, 2019 through December 15, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you should not be responsible for this copayment because the provider did not take care of you and you got really sick. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received SNF care from December 5, 2019 through December 15, 2019. Your EOC clearly states, for each admission you pay $20 per day for days 1-20 of a benefit period and $140 per day for days 21 -44 of a benefit period and $0 per day for days 45 -100 of a benefit period. Therefore, you are asked to pay a $200 copayment for the SNF 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 for SNF care from December 5, 2019 through December 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the operation and assembly of a pump (99190) provided on September 18, 2019.
You asked the Plan to pay for the pump operation and assembly. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump operation and assembly have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the operation and assembly of a pump (99190) provided on September 18, 2019.