Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient detoxification stay provided from May 23, 2019 to May 24, 2019.You asked the Plan to pay for inpatient stay. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this inpatient stay does not meet medical necessity criteria.The Plan follows Medicare rules. Medicare rules say that detoxification may be covered in an inpatient hospital setting if it is medically necessary for the enrollee to receive treatment at this level of 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 pay for inpatient stay. Our reviewer says that this inpatient detoxification stay does not meet the Medicare criteria for coverage. Our physician reviewer found this hospitalization does not qualify for inpatient payment. The emergency department evaluation showed no life-threatening conditions or evidence of acute substance withdrawal. The admission was voluntary and for the purposes of monitoring for the development of withdrawal symptoms. The care plan followed a standard template. The documentation is insufficient to support that detoxification services were medically necessary at an inpatient level of 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 inpatient stay have not been met.Therefore, we decided that the Plan does not have to pay foran inpatient detoxification stay provided from May 23, 2019 to May 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you foreyeglasses purchased from "the provider" on February 2, 2019.You asked the Plan to reimburse you forthe eyeglasses. You say that you ordered the eyeglasses from "the provider" because they are a less expensive optical provider. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 forcare from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
We looked at the file and the Plan's rules."the provider" is not a network provider with the Plan.The Plan did not pre-approve the eyeglasses. We found no exception that would require the Plan to reimburse you for the eyeglasses.Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to reimburse you foreyeglasses purchased from "the provider" on August 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical fluoride (D1206), periodontal maintenance
(D4910), and gingival irrigation (D4921) provided.
You asked the Plan to pay for the topical fluoride (D1206), periodontal maintenance (D4910), and gingival
irrigation (D4921). You say that the services should be covered at the in-network rate. The Plan denied your
request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the topical fluoride (D1206),
periodontal maintenance (D4910), and gingival irrigation (D4921) are not among those covered under this
benefit. Therefore, we decided that the Plan does not have to pay for the topical fluoride (D1206), periodontal
maintenance (D4910) and gingival irrigation (D4921) provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for Privigen injections (96365 and J1459) provided on August 5, 2019 through September 3, 2019.You asked the Plan to reduce the coinsurance forthe Privigen injections. You say that you were given an estimate for this service that was much lower than the actual bill. The Plan denied your request. The Plan says based on your coverage, there is a 20% coinsurance for in-network Medicare covered PartB prescription drugs.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 have been asked to pay 20% coinsurance for the Privigen injections. The Privigen injections fall 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 reduce the coinsurance for Privigen injections (96365 andJ1459) provided on August 5, 2019 through September 3, 2019. Your complaint about being given a lower estimate than the cost of the service 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) (45385) provided on November 6, 2018.You asked the Plan to waive the copayment for a colonoscopy. You say that you went for a screening colonoscopy not a diagnostic colonoscopy.You feel the copay should be zero due to a screening.The Plan denied your request. The Plan says outpatient surgery services have a $295 copayment for each visit. The Plan also says that per the provider's office, your appointment was scheduled for a diagnostic colonoscopy not a screening.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 $295 copayment for outpatient surgery services. You have been asked to pay a $295 copayment for a colonoscopy. This service falls within the outpatient surgery services benefit category. The record shows that your colonoscopy scheduled as diagnostic and resulted in the removal of a tumor, polyp or lesion. This is why the colonoscopy was not considered a screening and the outpatient surgery copayment was applied.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 fora colonoscopy with removal of tumor(s), polyp(s), or other lesion(s) (45385) provided on November 6, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay further for the comprehensive oral exam rendered to you on July 24, 2019.You asked the Plan to pay further for these services. You say that you disagree with the reimbursement amount.The Plan denied your request. The Plan says the claim was processed correctly.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay further for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Your supplemental dental benefit is covered by the Medicaid portion of your plan, not Medicare. Therefore, we decided that the Plan does not have to pay further for the comprehensive oral exam rendered to you on July 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97535 and 97530) provided on August 26, 2019.You asked the Plan to pay for occupational therapy services. You say that these services were medically necessary.The Plan denied your request. The Plan says these services were not authorized.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 pay for occupational therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the patient's condition of a stroke dating back to October 2018 with chronic weakness. The patient should be versed in a home exercise program at this point. The patient has had extensive therapy for this condition and her functional status did not require the unique skills of a professional therapist to safely and effectively provide treatment. 
Services do not need to be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy services have not been met.Therefore, we decided that the Plan does not have to pay for occupational therapy services (97535 and 97530) provided on August 26, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forneurology services provided on July 10, 2018.You asked the Plan to pay forneurology services. You say that you have met the timely filing obligations, and the Plan's lack of receipt was caused by an internal issue.The Plandenied your request. The Plan says the denial of payment for these services is correct, because this claim was not filed within the timely filing limits.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 neurology services was not filed until July 12, 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 forneurology services provided on July 10, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from June 21, 2019 to June 23, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not aware that the copayment would be that high. You say you have never had to pay that high of a bill. 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 $200 copayment for medically necessary in-network inpatient hospital care. You have been asked to pay a $200 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital 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 inpatient hospital stay provided from June 21, 2019 to June 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on August 5, 2019 by the out of network provider.
You asked the Plan to pay for the practitioner service. You say that the services were provided to the enrollee at the request of the nursing facility where the enrollee resided. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.
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 referring facility is not a network provider either. 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 annual wellness visit provided on August 5, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on January 23, 2019 by out of network provider, "the provider"..You asked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe office visit provided on January 23, 2019 by out of network provider, "the provider".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 resin-based composites -4 or more surfaces, posterior resin-based composite -2 surfaces, 2 anterior resin-based composites -2 surfaces, andamalgam -4 or more surfaces provided on October 1, 2019.You asked the Plan to pay for the resin-based composites and amalgam. The Plan denied your request. The Plan says these services are not covered under Medicare.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 2 resin-based composites -4 or more surfaces, posterior resin-based composite -2 surfaces, 2 anterior resin-based composites -2 surfaces, and amalgam -4 or more surfaces provided on October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 22, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay the copayment because you were transferred from the emergency room to another building on the campus.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 one-way trip. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The record shows you were transported by ambulance.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 ambulance transport provided on June 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 26, 2019 to May 30, 2019 by out of network providers.
You asked the Plan to pay for office services. You say that you did not know that you would be seen by these providers at these visits and did not know they were out-of-network. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these providers are out-of-network with the Plan and prior authorization was not 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 providers 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 medical services provided on March 26, 2019 to May 30, 2019 by out of network providers.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora diagnostic colonoscopy provided on August 5, 2019.You asked the Plan to waive the coinsurance fora diagnostic colonoscopy. You say that this should be billed as preventative.The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for outpatient surgery/in-network/ambulatory surgical center. You have been asked to pay a 20% coinsurance of the allowed amount for a diagnostic colonoscopy. The total allowed amount is $698.46. The total amount you are being asked to pay is $139.69 ($698.46 x 20% = $139.69). Evidence shows that the colonoscopy that was provided was diagnostic in nature; therefore, the correct coinsurance has been applied. A diagnostic colonoscopy falls within the outpatient surgery/in-network/ambulatory surgical center 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 fora diagnostic colonoscopy provided on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided tothe enrollee on June 3, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid and the service is necessary.The Plan denied your request. The Plan says the documentation does not support medical necessity.The Plan follows Medicare rules. Medicare rules say that knee instability must be documented by examination of the beneficiary and objective description of joint laxity. 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 pay for the orthoses. Our reviewer says that the orthoses were not medically necessary. Our physician reviewer found The documentation in the case file does not support thatthe requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided.
You asked the Plan to waive the copayment for specialist services. You say that you do not know why you are
being charged a hospital fee when you saw a doctor. 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 $50
copayment for physician/practitioner services/in-network/specialist.
You have been asked to pay $42.67 which is less than your copayment amount of $50 for specialist services.
The services that were provided were specialist services; therefore, the correct copayment has been applied.
Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code S9999,
A6533 that were issued.
You asked the Plan to pay for the compression stockings. You say that the claim should be paid. The Plan
denied your request. The Plan says these stockings are non-reusable supply items, and therefore not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code S9999,
A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression
stockings identified with code S9999, A6533 that were issued.