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

We decided that the Plan does not have to pay for contact lenses purchased on October 18, 2019.
You asked the Plan to pay for the contact lenses. You say that you were told that you can get up to $100 reimbursed for contacts. You spent $96.99 and you were reimbursed $50. In the past you have always received the full amount back. The Plan denied your request. The Plan says this claim was processed correctly per the Evidence of Coverage.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that there is a $100 allowance towards the cost of routine eye wear every two years from plan and non-plan providers. The plan has confirmed that on March 7, 2019 you were fitted for contact lenses and $50 was reimbursed from the eye wear allowance, leaving $50 for the allowance. You have been asked to pay $47 for the contact lenses. The contact lenses fall 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 pay for contact lenses purchased on October 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to the skilled nursing facility (SNF) requested on February 25, 2020.You asked the Plan to pre-approvethe SNF admission. You say that you feel that you need to receive care in the SNF.The Plan denied your request. The Plan says the enrollee has not been compliant with the care being received at the SNF thus far.There is no evidence that she would participate in daily skilled therapy and she does not require daily nursing care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 75 year old female who was hospitalized from 12/5/19 to 2/11/2020 for CHF and vertebral osteomyelitis when she was admitted to the SNF without prior auth. After atime, Part A coverage was requested and denied. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. The beneficiary was at a contact guard to minimal level with functional mobility including gait to 110 feet with a rolling walker. The beneficiary required varying assist with ADLs.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON services. You say that therapy is important to avoid surgery.The Plan denied your request. The Plan says care is available within 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 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 noexception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve(E2310) electronic connection, (E2377) expandable controller and (E2313) expandable controller harness, (K0108) memory seat program, (K0108) USB charger,  (K0108) phone holder and (E2300) seat elevator.  You asked the Plan to pre-approvethe wheelchair accessories. You say that the power actuators will not function as intended in the absence of either of these components.The Plan denied your request. The Plan says the electronic connection, expandable controller, and an expandable controller harness are not medically necessary. The Memory Seat program, USB Charger, Phone Holder and Seat Elevator do not serve a primary medical purpose and cannot be covered.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 wheelchair accessories. Our reviewer says thatthe requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee's strength is sufficient to control the power options with their separate switches already included with the approval of these power options. The memory seat program, USB charger, phone holder and seat elevator do not serve a primary medical purpose and therefore do not meet Medicare guidelines that indicate the equipment is necessary and reasonable for the treatment of the patient's illness or injury or to improve the functioning of his or her malformed body member.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 wheelchair accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve(E2310) electronic connection, (E2377) expandable controller and (E2313) expandable controller harness, (K0108) memory seat program, (K0108) USB charger,  (K0108) phone holder and (E2300) seat elevator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says after several attempts to obtain clinical documentation, none was received.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence (radiology reports) to support the diagnosis of osteoarthritis. There is no documentation of attempted, and failed, conservative therapy (medications, PT/OT, exercise, weight loss, injections).
Therefore, the requested Monovisc is not shown to be currently medically necessary and reasonable. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Monovisc for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on December 6, 2019 by an out of network (OON) provider. You asked the Plan to pay for the orthosis. You say that the medical records and the doctor's orders clearly demonstrate medical necessity for the devices prescribed and you feel this claim should be approved. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 shoulder elbow wrist hand orthosis provided on December 6, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971x2) provided on December 4, 2019.You asked the Plan to pay for the ankle foot orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records submitted did not include documentation to support that the replacement was necessary due to loss or irreparable damage.The Plan must follow Medicare rules. Medicare rules say that in no case can the reasonable useful lifetime of DME be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis have not been met. Specifically, the record indicates that the member received the same item on March 5, 2018. The record does not include documentation to support that the replacement was necessary due to loss or irreparable damage. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (L1971x2) provided on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on September 25, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you were told that you would only owe a $25 specialist copayment. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on September 25, 2019. The allowed amount for the drug is $4,238.10 and 20% of that is $847.62. You have been asked to pay the total coinsurance amount of $847.62 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on September 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the CT scan provided on December 7,
2019.
You asked the Plan to reduce the copayment for the CT scan. You say that you thought you would only be
responsible for a $30 copayment. You say no one at the facility told your copayment would be $150. 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 $150
copayment for each Medicare-covered service.
You have been asked to pay a $150 copayment for the CT scan. The CT scan 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 reduce
the copayment for CT scan provided on December 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain
management infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (S9328) provided to the enrollee from February 8, 2019 to April 3, 2019.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that this is not
covered by Medicare.
The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered
as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan
does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan
does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay
for the home infusion therapy, implanted pump pain management infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided
to the enrollee from February 8, 2019 to April 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the immediate upper denture (D5130) provided on
February 25, 2019.
You asked the Plan to reimburse you for the dental item. You say that after you looked at your benefits, you
saw some dollars that have not been used. You say that is why you got the partial bridge. You also say that you
were advised you would be reimbursed for this. The Plan denied your request. The Plan says immediate partial
dentures are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the immediate denture is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the
immediate upper denture (D5130) provided on February 25, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the wheezing evaluation provided on October 14, 2019.
You asked the Plan to waive the copayment for the wheezing evaluation. You say that this was a preventive service during your annual physical. You say that you were not informed of potential liability. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for other outpatient diagnostic tests. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $20 copayment the wheezing evaluation. The Plan contract does not clearly say how much enrollees must pay for other outpatient diagnostic tests. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the wheezing evaluation provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacupuncture treatment (97813) with out of network (OON) provider.You asked the Plan to pre-approvethe acupuncture treatment. You say that acupuncture treatmentisnecessary as you are experiencing lower back pain, neck, shoulder, and knee pain. Additionally, you say that the Plan does not have providers within your areato renderthis service.The Plan denied your request. The Plan says the requested provider is not an in-network provider with the Plan. There are available contracted providers that may render the service requested.Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible toan enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. The requested provider in this case is not a network provider with the Plan. We were able to confirm that the Plan has a contract provider located within reasonable distance and travel time from your home who can provide acupuncture treatment. Under Medicare rules, this means that contract providers are accessible to you. Therefore,we decided that the Plan does not have to pre-approveacupuncture treatment (97813)with the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy services provided on
December 11, 2019.
You asked the Plan to waive the copayment for radiation therapy services. You say that the cost is a lot. You
say that you want help with the copayment. 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 each Medicare-covered, in-network, radiation (radium and isotope) therapy service.
You have been asked to pay a $60 copayment for radiation therapy services. Radiation therapy services 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 radiation therapy services provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the manual wheelchair and attachments
provided on October 14, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you cannot afford this. The Plan
denied your request. The Plan says that you were charged 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 20%
coinsurance for Medicare-covered durable medical equipment.
You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare covered
durable medical equipment benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for
the manual wheelchair and attachments provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gastroenterology consultation at the tertiary level of care to be provided.
You asked the Plan to pre-approve tertiary gastroenterology services. You say that you are in pain and this is the best doctor. The Plan denied your request. The Plan says the denial of authorization for treatment at the tertiary level of care is correct, because you can be treated by a non-tertiary level provider. The Plan also says that, if after evaluation with a non-tertiary provider, the provider feels that tertiary level of care is necessary, then the requested tertiary level of care could be approved.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 tertiary gastroenterology services. Our reviewer says that you do not meet the Medicare criteria for treatment at the tertiary level of care at this time. Our physician reviewer found the records do not support a severity of symptoms, complexity of co-morbidities, or presence of alarm signs or symptoms to warrant pursuit of a tertiary level of care at this time. Appropriate expertise is available locally within your primary network for your care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tertiary gastroenterology services have not been met. Therefore, we decided that the Plan does not have to pre-approve gastroenterology consultation at the tertiary level of care to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmology exam (92012) provided October 16, 2019 to October 23, 2019.
You asked the Plan to waive the copayment for the vision services. You say that you went to this provider for an ongoing problem with dry eye. She informed you that if this did not help to return in one week. Everything was a routine visit so why the $35 copay for each visit. The Plan denied your request. The Plan says these claims were processed correctly and the correct copayment was applied.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay $35 copay for all other Medicare covered eye exams for Vision care. You have been asked to pay $70 for the vision services ($35+$35=$70). The vision services fall 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 ophthalmology exam (92012) provided October 16, 2019 to October 23, 2019.