Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and erupted tooth extraction provided on August 19, 2019.
You asked the Plan to pay for the intraoral x-ray and erupted tooth extraction. You say that the Plan says that tooth extractions and related matters would be covered. You say that payment should be approved. The Plan denied your request. The Plan says these are not covered benefits.
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 pay for the intraoral x-ray and erupted tooth extraction provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on August 1, 2019.
You asked the Plan to waive the copayment for the podiatry visit. You say that the doctor's office told you that they accept all insurance and there would be no copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $55 copayment for each out-of-network Medicare-covered podiatry visit. You have been asked to pay a $55 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. The record shows your provider is out-of-network.
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 podiatry visit provided on August 1, 2019.
Your complaint about your shoe order is 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 laboratory services received were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 27, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you get a scan during every visit. You say that you shouldn't have two copayments. 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 $60 copayment for in-network Medicare-covered x-rays and ultrasounds. You have been asked to pay a $60 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on September 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9500
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 S9500 is Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9500 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9500
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution , and lancet device provided from June 8, 2019 to August 27, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution , and lancet device provided from June 8, 2019 to August 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 9, 2019 through August 21, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were scheduled for a prostate biopsy and almost lost your life. 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 that you were admitted on August 9, 2019 and discharged on August 21, 2019. You were asked to pay a $190 copayment per day from August 9, 2019 through August 17, 2019, days 1-9 of your inpatient stay. There were no copayment charges from August 18, 2019, day 10 of your inpatient hospital care until your day of discharge August 21, 2019. Per your contract there is a $190 copayment per day required for days 1-9. 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 care provided from August 9, 2019 through August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the optometrist office visit provided on August 14, 2019.
You asked the Plan to waive the copayment for the optometrist office visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for subsequent Medicare-covered or routine visits. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for the optometrist office visit.
You have been asked to pay a $19.99 copayment for the optometrist office visit. The optometrist office visit falls within the "Vision 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 optometrist office visit provided, on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided on October 1, 2019.
You asked the Plan to pay for the intraoral x-ray. You say that you should have been informed if they were not bitewing. You say that you were unfairly charged. The Plan denied your request. The Plan says this 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 pay for the intraoral x-ray provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Continuous Positive Air Pressure (CPAP) accessories (A7039, A7038, A9900) provided on August 31, 2018.
You asked the Plan to pay for the CPAP accessories. You say that it was less expensive to purchase the items from the out-of-network provider than the contracted provider. The Plan denied your request. The Plan says the items at issue were not emergent and there are providers in-network that can provide the items. There was no pre-authorization to purchase the items out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 Continuous Positive Air Pressure (CPAP) accessories (A7039, A7038, A9900) provided on August 31, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 13.
You asked the Plan to pre-approve the dental service. You say that the enrollee broke her tooth bridge during an epilepsy attack. You also say that crowns for teeth # 12 and 14 have been approved. The Plan denied your request. The Plan says although crowns are a covered service, tooth # 13 is missing. The Plan also says that crowns cannot be approved for teeth that do not exist.
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 crowns are a covered service, the service is being requested for a tooth that is missing. Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vitrectomy table (E1399) provided by the facility.
You asked the Plan to pre-approve the vitrectomy table.. You say that you are requesting reconsideration of the
post-operative medical equipment you needed following vitrectomy surgery. The Plan denied your request. The
Plan says this item is not a covered benefit.
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 a vitrectomy table (E1399) provided by the facility.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the removal of breast implants and replacement of new breast implants (19328, 19342, and 19380).
You asked the Plan to pre-approve the removal of breast implants and replacement of new breast implants. You say that the requested services are medically necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. 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 removal of breast implants and replacement of new breast implants. Our reviewer says that the services are medically necessary. Our physician reviewer found one of the goals of the requested reconstruction is to address complications from your original medically necessary breast reconstruction. You have asymmetry and deformity as the result of the medically necessary reconstruction. Further revision with implant exchange to address these complications would be reconstructive as well. In addition, the planned procedures would help to reduce the 6-time increase in development of BIA-ALCL, which is a malignancy. Thus, this satisfies the coverage criteria, as the procedure is being performed to prevent malignancy(treatment of illness) and to treat complications of your original medically necessary breast reconstruction. 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 removal of breast implants and replacement of new breast implants have been met. Therefore, we decided that the Plan has to pre-approve the removal of breast implants and replacement of new breast implants (19328, 19342, and 19380).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 10, 2019 through August 16, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan states that a refund was issued on October 14, 2019 for the emergency room.
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 inpatient hospital care provided from August 10, 2019 through August 16, 2019. You were asked to pay a $195 copayment per day from August 10, 2019 through August 15, 2019, days 1-6 of your inpatient hospital care. You were discharged on August 16, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $195 copayment per day required for days 1-9. 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 care provided from August 10, 2019 through August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from July 31, 2019 to October 19, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from July 31, 2019 to October 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (93970) provided on May 8, 2019 by out of network provider.You asked the Plan to pay forthe duplex scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the out-of-network services were not pre-authorized. There are in-network providers that can provide the services at issue.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 forthe medical services (93970) provided on May 8, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (88305) provided on January 23,
2019 by the out of network provider.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says while the out-of-network services may have been medically necessary, no
referral or pre-approval 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 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 laboratory services (88305) provided on
January 23, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) and the x-ray exam of the neck and spine (72040) provided on February 11, 2019.
You asked the Plan to pay for the office visit and the x-ray exam of the neck and spine. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the services provided are not a covered benefit under your policy.
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. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and the x-ray exam of the neck and spine (72040) provided on February 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on August 23, 2019.
You asked the Plan to pay for the air ambulance service. You say that the transport was medically necessary. The Plan denied your request. The Plan says Medicare does not cover transport back to the United States from a foreign country.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if the enrollee's medical condition is such that transportation by ground ambulance is not appropriate and the enrollee is transported to the closest appropriate facility. Transports from a hospital in connection with a covered foreign hospitalization are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for services provided on August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the pathology consultation provided on September 12, 2019.
You asked the Plan to waive the deductible for the pathology consultation. You say that you were informed the provider was in-network. You say that you expect to be billed in-network. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the pathology consultation was received on September 12, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the pathology consultation provided on September 12, 2019.