Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve behavioral health services provided by the physician.
You asked the Plan to pre-approve the behavioral health services. You say that you have been seeing the physician for almost five years and he has helped you tremendously with major depression and anxiety. You say it is important for your well-being to continue care with this provider. The Plan denied your request. The Plan says your plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty 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 pre-approved care. The contract with the Plan also says that your plan requires you to receive care from providers who are part of your primary care physician's (PCP) specialty network.
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 behavioral health services provided by the physician.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 21, 2019 by the out of network provider.
You asked the Plan to pay for the non-emergent ambulance services. You say that the transport was medically necessary. The Plan denied your request. The Plan says you did not request prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 21, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on February 5, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on February 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic outpatient services or the Part B injection provided from April 18, 2019 to June 28, 2019.
You asked the Plan to waive the cost share for the diagnostic outpatient services and the Part B injection. You sent a copy of your bills for review. 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 $40 copayment for in-network diagnostic procedures and tests and 20% coinsurance for all other in-network drugs covered under Medicare Part B. You have been asked to pay a total of $500 for the diagnostic outpatient services and the Part B injection. The diagnostic outpatient services fall within the "Outpatient hospital services" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment/Coinsurance
Member Liability
April 18, 2019
Cystoscopy
$248.17
$40.00
$40.00
May 24, 2019
Treatment of bladder lesion
$131.90
$40.00
$40.00
May 31, 2019
Treatment of bladder lesion
$131.90
$40.00
$40.00
May 31, 2019
Interferon injection
$1,500.00
20%
$300.00
June 7, 2019
Treatment of bladder lesion
$131.90
$40.00
$40.00
June 28, 2019
Treatment of bladder lesion
$131.90
$40.00
$40.00
Total
$500.00
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 cost share for the diagnostic outpatient services or the Part B injection provided by from April 18, 2019 to June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on September 3, 2019.
You asked the Plan to waive the copayment for the specialist 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on September 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on September 5, 2019.
You asked the Plan to pay for the eyewear. You say that you do not feel this benefit has been exhausted because the Cornerstone representative said that on the website it showed you were still eligible for $100 otherwise you would not have gotten the eyewear. The Plan denied your request. The Plan says the $100 vision benefit for 2019 has been exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $100 vision benefit for in-network and out of network providers once a year. We looked at the file and the Plan's rules. the $100 vision allowance benefit was issued on April 19, 2019. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup.You asked the Plan to pre-approve the dental services. You say that you want your teeth to be preserved, and prevent further tooth damage.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 pre-approve a core buildup.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided by an out-of-network provider, on August 17, 2019 to August 27, 2019.
You asked the Plan to waive the copayment for urgent care. You say that this amount is way more than what you were told. 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 $65 copayment for urgently needed services/out-of-network. You have been asked to pay a $65 copayment for urgent care. The total amount you are being asked to pay is $195 ($65 x 3 visits = $195). Urgent care falls within the urgently needed services/out-of-network 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 urgent care services provided by an out-of-network provider, on August 17, 2019 to August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA breast cancer testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has never had cancer.
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 test at issue in this appeal, the testing, is being requested solely for screening purposes. The enrollee does not have a personal history of cancer. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve BRCA breast cancer testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided to the enrollee

You asked the Plan to pre-approve the physician's services for a second opinion. You say that the Plan providers have not been able to help you with the constant pain and the increasing disability you have experienced. You say you would like a second opinion with a different facility. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 

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 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. 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 physician's services for a second opinion to be provided to the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says you have a medical only policy with the Plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the duplex scan or the CT scan provided on July 31, 2019 and August 7, 2019.
You asked the Plan to waive the coinsurance for the duplex scan and the CT scan. You say that you have never had a bill before. You say you were told you would not have any copayments with this plan. 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 20% coinsurance per visit for CT scan/ultrasound. Deductible does not apply. You have been asked to pay a total of $32.07 for the duplex scan, the ultrasound, and the CT scan. The duplex scan and the CT scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
July 31, 2019
Duplex scan
$70.37
20%
14.08
August 7, 2019
CT scan
$91.29
20%
$17.99 - This is less than the standard amount.
Total
$32.07
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 duplex scan or the CT scan provided on July 31, 2019 and August 7, 2019.
Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the heavy duty wheelchair and accessories provided on April 25, 2019.
You asked the Plan to pay for the heavy duty wheelchair (K0006) and accessories. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the submitted order does not include a completed physician's order and the documentation did not include an itemized shipping invoice or 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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the heavy duty wheelchair and accessories provided on April 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on June 18, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided by on June 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the lightweight wheelchair purchased on September 3, 2019
You asked the Plan to reimburse you for the lightweight wheelchair. You say that after surgeries you were unable to walk so you had to buy a wheelchair because you were denied a wheelchair by the Plan. The Plan denied your request. The Plan says Medicare only covers durable medical equipment if the supplier is enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the lightweight wheelchair purchased on September 3, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on July 10, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that the cologuard test produced a false positive. You say that this should be billed as preventive. 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 $275 copayment for surgical services at an in-network ambulatory surgical center. You have been asked to pay a $275 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes. 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 diagnostic colonoscopy provided on July 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from May 4, 2019 to May 6, 2019.
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 were never told you were there for observation. You say the doctor told you that you were going to be admitted. 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 $100 copayment for each in-network Medicare-covered emergency room visit. You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were admitted to observation.
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 May 4, 2019 to May 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tubal ligation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that tubal ligation is not covered when it is primarily for sterilization. The requested service is primarily for sterilization. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve tubal ligation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need new orthotics because your foot condition is causing you foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.