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

We decided that the Plan does not have to pay for gym membership fee You asked the Plan to pay for gym membership fee. You say that you would like to be reimbursed the unpaid balance of $205.31 for the 2020 annual gym membership.The Plan denied your request. The Plan says this claim was processed correctly per the Evidence of Coverage.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits up to $240 per year. The date of service for this benefit is the day you make payment. For example, if you pay on December 15 for a gym membership that starts January 1. December 15 is the date of service. You paid for the services on December 31, 2019, therefore, this applies to the 2019 health and wellness  and you have been reimbursed the full amount of $240 for the 2019 year.The Plan's rules for coverage of gym benefits have not been met because this service was paid December 31, 2019. Therefore, this applies to the 2019 health and wellness benefit not 2020.Therefore, we decided that the Plan does not have to pay for gym membership fee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio for the enrollee.
You asked the Plan to pre-approve Entyvio. You say that the enrollee needs this because of her medical condition. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Entyvio. Our reviewer says that Entyvio is not medically reasonable and necessary for the enrollee in this case. The case file does not contain documentation of trial and failure of Stelara. The documentation does not support that Stelara would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Entyvio. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each (A4351) and lubricant, individual sterile packet, each (A4332) provided on December 6, 2018 by an out-of-network provider.You asked the Plan to waive the coinsurance for the DME. You say that you do not feel liable for the services.The Plan denied your request. The Plan says they adjusted the claim to your in-network benefits as the services were requested by an in-network provider.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 DME on December 6, 2018 by an out-of-network provider. You were asked to pay 50% coinsurance because you used an out-of-network provider; however, the Plan found that an in-network provider requested the services. Therefore, the Plan processed the claim with your in-network benefits. You are asked to pay 20% coinsurance for the DME at the in-network rate. 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 intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each (A4351) and lubricant, individual sterile packet, each (A4332) provided on December 6, 2018 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intermittent urinary catheter, with insertion supplies (A4353) provided to the enrollee on January 20, 2020.
You asked the Plan to waive the coinsurance for the supplies. You say that you are appealing the member's cost-share responsibility for the services the member received because they cannot pay the payment each month and they never had to pay it before. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2020 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 the enrollee received medical supplies on January 20, 2020. The enrollee is asked to pay 20% coinsurance for the medical supplies. The enrollee's EOC states, they must pay 20% coinsurance for prosthetic devices and medical supplies. 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 coinsurance for intermittent urinary catheter, with insertion supplies (A4353) provided to the enrollee on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tympanometry testing (92567), the comprehensive hearing test (92557), and the office visit (99203) rendered by the out of network (OON) provider on November 13, 2019.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided by an out of network provider, without 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 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 tympanometry testing (92567), the comprehensive hearing test (92557), and the office visit (99203) rendered by the out of network (OON) provider on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth # 5 and 7 provided on December 30, 2019.You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that the dental rider would not be of much benefit. You also say that you were not advised that there was a $500 benefit maximum.The Plan denied your request. The Plan says there is a maximum allowance of $500 per year. The Plan also says that the maximum allowance has been exceeded.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 maximum benefit of $500 has been exceeded. Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 5 and 7 provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 5, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this visit was for a routine follow-up for diabetes. You say there should be no copayment for a diabetes screening. 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 $15 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a routine visit, which is not a considered routine 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 office visit provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120). You asked the Plan to pre-approve the dental items. You say that your lower denture has been broken beyond repair. You also say that you need a new one.The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan says that the frequency limit has been exhausted. The Plan also says that you last received dentures on December 18, 2018, less than 5 years 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 rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are a covered service, the frequency limit of once every 5 years has been exhausted.Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on January 2, 2020.You asked the Plan to waive the copayment for the breast ultrasound. You say that you disagree with the ultrasound because the routine mammogram was not clear. 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 each in-network Medicare-covered standard x-ray and ultrasound. You have been asked to pay a $50 copayment for the breast ultrasound. The breast 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 breast ultrasound provided on January 2, 2020.Your complaint that the ultrasound charge is misleading and unfair 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: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on February 3, 2020.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on December 27, 2019.
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges because you were not informed why the test was being done. 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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall 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 laboratory tests provided on December 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total hip replacement to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve the total hip replacement to be provided by an out-of-network provider. You say that eleven years ago you had left hip surgery done at this facility with the same physician. You say this physician did so well with your left hip surgery that you would like to have him perform surgery for your right hip. The Plan denied your request. The Plan says you may obtain services from out-of-network providers only in emergent/urgent situations or when the services are not available within the 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a total hip replacement to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 10, 2016. 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 claim was not filed timely. The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until December 30, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 10, 2016.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has uncontrolled gastroparesis. The data in the medical literature are conflicting regarding the efficacy of botulinum toxin injections for the treatment of gastroparesis. There have been open-label trials showing good clinical response to botulinum toxin, but randomized controlled trials of the drug have not demonstrated objective improvement in gastric emptying. Botox for the treatment of gastroparesis would be considered experimental and investigational at this time. The services are therefore not reasonable or medically necessary. 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 Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture (D5211), and an immediate lower denture (D5222). You asked the Plan to pre-approve the dentures. You say that you need the immediate denture because once you get your teeth extracted, you will no longer have teeth that you need in order to eat. The Plan denied your request. The Plan says the immediate partial denture is not a covered service. The Plan says that partial dentures are covered once every 5 years. The Plan also says that the frequency 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 partial dentures are listed as a covered service, the frequency limit of once every 5 years has been exhausted. The record shows that you last received a partial denture on October 24, 2018. Additionally, immediate partial dentures are not a covered service.Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5211), and an immediate lower denture (D5222).
Appeal type: Practitioner Services
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 October 25, 2019.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 providersavailable 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 October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered from May 20, 2019 to November 21, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not Medicare certified. The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the physician services rendered from May 20, 2019 to November 21, 2019.
Appeal type: Lab
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 14, 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 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397)
provided to the enrollee on November 7, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 7, 2019.