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

We decided that the Plan does not have to reimburse the coinsurance for durable medical equipment (DME) supplies (A7038, A7046, A7039, A7035) provided on March 29, 2021.
You asked the Plan to reimburse the coinsurance for DME supplies. You say that you did not request the items that were sent to you but decided to keep the face mask assembly. You also say that the company refused to issue a credit for returned items. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 20% coinsurance for each Medicare-covered durable medical equipment (DME) and related supplies.
You have been asked to pay a 20% coinsurance for DME supplies. The EOC confirms you pay a 20% coinsurance for all DME equipment and supplies. The records show disposable filters (A7038) for a continuous positive airway pressure CPAP device were purchased. The allowed amount of the claim is $20.63, resulting in a coinsurance obligation of $4.13. The records show a water chamber (A7046) for a CPAP device was purchased. The allowed amount of the claim is $15.61, resulting in a coinsurance obligation of $3.12. The records show non-disposable filters (A7039) for a CPAP device was purchased. The allowed amount of the claim is $12.26, resulting in a coinsurance obligation of $2.45. The records show headgear (A7035) for a CPAP device was purchased. The allowed amount of the claim is $19.56, resulting in a coinsurance obligation of $3.91.
The records show a replacement face mask (A7031) for a CPAP device was purchased. The allowed amount of the claim is $167.46, resulting in a coinsurance obligation of $33.49.
The records show tubing (A7037) for a CPAP device was purchased. The allowed amount of the claim is $31.37, resulting in a coinsurance obligation of $6.27.
The records show a full-face mask (A7030) for a CPAP device was purchased. The allowed amount of the claim is $92.85, resulting in a coinsurance obligation of $18.57.
The total cost-share for these supplies is $71.94 ($4.13 + $3.12 + $2.45 + $3.91 + $33.49 + $6.27 + $18.57 = $71.94. The Plan has indicated that the supplier has issued credit for the returned equipment. 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 reimburse the coinsurance for durable medical equipment (DME) supplies (A7038, A7046, A7039, A7035) provided on March 29, 2021.
Your complaint about the company refusing to issue a credit for returned supplies 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided April 9, 2021.
You asked the Plan to pay for the diagnostic service. You say that the diagnosis code listed on the claim are appropriate diagnosis codes per CMS guidelines. The Plan denied your request. The Plan says the diagnosis Z86.718 is not one of the listed diagnosis codes that support medical necessity for procedure 93970.
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. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins (93970) provided April 9, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on May 2, 2021. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you feel like they 
dropped the ball. You say that you are very upset. The Plan denied your request. The Plan says the correct 
copayment has been 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 $90 
copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was 
provided, the correct copayment has been applied. An emergency room visit falls within the emergency 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 an emergency room visit 
provided by a participating provider on May 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (82310, 82435, 82565, 82947, 84295, 
84520) provided on December 21, 2020, by an OON provider. 
 
You asked the Plan to pay for laboratory services. You say that you spend four months in Arizona each year 
due to your congestive heart failure and the inability to tolerate the coldest months in New York. The Plan 
denied your request. The Plan says services were provided 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 records show that your policy 
with this Plan did not have out-of-network coverage through December 31, 2020. The records also show that 
you updated your policy with the Plan to cover out-of-network benefits through a point-of-service (POS) Plan 
which became effective January 1, 2021. The Plan had network providers available who could have provided 
the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records 
provided for review do not show that the services at issue were urgent or emergent. 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 laboratory services (82310, 82435, 82565, 82947, 84295, 84520) provided on December 21, 2020, by an 
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a Medicare plan may restrict members to a network of providers as long as medically 
necessary covered care is accessible and available through this network. The rules say that the Plan must 
arrange for specialty care outside of the Plan provider network when network providers are unavailable or 
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that, with limited exceptions, members of the Plan must use network providers to get medical care 
and services. The only exceptions are emergencies, urgently needed care when the network is not available 
(generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan 
authorizes the use of out-of-network providers. You can find this information on page 47 of the Plan's 2021 
EOC.We decided that the Plan does not have to pre-approve the office consultation for a new or established patient 
(99244) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office consultation for a new or established patient. You say that this is 
medically necessary. The Plan denied your request. The Plan says they have in-network providers available to 
treat the enrollee's condition. 
 
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 office consultation for a new or established patient (99244) to be provided by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80053, 83036, 80061, 36415) provided on April 19, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that you are requesting reconsideration. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 laboratory services (80053, 83036, 80061, 36415) provided on April 19, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care provided from August 26, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that these services are medically necessary. The Plan denied your request. The Plan says the criteria for continued inpatient psychiatric care have not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psychiatric care. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found that you do not require inpatient mental health treatment as you are not a danger to yourself or others and do not have any delusions, auditory or visual hallucinations. It does not appear that active treatment was taking place. It does not appear that the services for were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment and could have been treated in a lesser restrictive setting as you are not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care provided from August 26, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the trigeminal division block anesthesia (D9212) provided February 10, 2021, and the cleaning and inspection of removable complete denture, maxillary (D9932) provided March 23, 2021.
You asked the Plan to pay for the trigeminal division block anesthesia and the cleaning and inspection of the removable complete upper denture. You say that the services were necessary, and you do not understand why they are not covered. The Plan denied your request. The Plan says these services are not covered under your 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 trigeminal division block anesthesia (D9212) provided February 10, 2021, and the cleaning and inspection of removable complete denture, maxillary (D9932) provided March 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 2, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you experienced side effects from a medication you received, which caused you to return to the emergency room. The Plan denied your request. The Plan says you have been asked to pay 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 $35 copayment for each emergency room visit.
You have been asked to pay a $35 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. The record shows you received services during your emergency room visit. 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 emergency room visit provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 24, 2021.
You asked the Plan to pay for lab test. You say that you had an obligation to stabilize the enrollee, and services were rendered in good faith. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is not eligible to participate in Medicare and is not payable.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. This provider is not enrolled in the Medicare program and is not payable. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 16, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that all other dates of service have been processed and paid by this enrollee's Plan. You say you would like the claim reprocessed as a one-time consideration. 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 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 office visit provided on November 16, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on February 12, 2021.
You asked the Plan to pay for the testing services. You say that the testing is a medically necessary covered benefit. The Plan denied your request. The Plan says the panel is non-covered by Medicare.
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 rules say that the testing is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel provided on February 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on February 10, 2021. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were not informed that you would 
owe anything for diagnostic radiology services. 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 a $225 
copayment for advanced radiology services. You have been asked to pay a $225 copayment for an MRI. An MRI 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 
an MRI provided on February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2313, E2311, E2377).
You asked the Plan to pre-approve the expandable controller. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when medically necessary. 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 expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found
although there are three approved power options on this wheelchair (tilt, recline, and elevating leg rests), there is not a medical need to control these power options through the joystick. The enrollee can operate these functions with the standard switches. 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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2313, E2311, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a chiropractor from 
April 12, 2021, to May 10, 2021. 
 
You asked the Plan to pay for chiropractic services. You say that you should only have to pay your $20 
copayment. The Plan denied your request. The Plan says while they paid those services allowed by Medicare, 
the Plan contract is clear that only manual manipulation of the spine is covered. 
 
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 physical 
therapy services provided by a chiropractor from April 12, 2021, to May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the visit you had at an outpatient hospital clinic on April 22, 2021.
You asked the Plan to reduce the cost sharing for the hospital clinic visit. You say that this is an outrageous amount of money to pay for a state-funded hospital The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that because the allowed amount for this service ($135.35) is less than your copayment obligation, you are responsible for the full allowed 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 $475 copayment for non-surgical visits to an outpatient hospital clinic.
You have been asked to pay a $475 copayment for the hospital clinic visit. 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 cost sharing for the visit you had at an outpatient hospital clinic on April 22, 2021.