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

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 10, 2020.
You asked the Plan to pay for the orthosis. You say that this should be processed for payment. The Plan denied your request. The Plan says that documentation indicates services are not necessary for treatment of the patient's condition.
The Plan must follow Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care and specialist services provided by a participating provider on November 2, 2020, to December 21, 2020.

You asked the Plan to waive the copayment for wound care and specialist services. You say that you did not have surgery. You say that you are being overcharged. The Plan denied your request. The Plan says the correct copayments have 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 $195 copayment for outpatient surgery and a $35 copayment for physician/practitioner services/specialist.

You have been asked to pay a $195 copayment for wound care and a $35 copayment for specialist services.

Total Amount Being Asked to Pay: $1,029.04 ($195 + $195 + $35 + $195 + $179.04 + $35 + $195).

Wound care falls within the outpatient surgery benefit category. Specialist services fall within the physician/practitioner services/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 wound care and specialist services provided by a participating provider on November 2, 2020, to December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for interrogation device evaluations provided from October 21, 2020, to December 1, 2020.

You asked the Plan to waive the copayments for interrogation device evaluations. You say that you were not informed that you would owe copayments and feel that they are not warranted. 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 $50 copayment for non-radiological diagnostic services. 

You received an interrogation device evaluation on October 21, 2020. An interrogation device evaluation is considered an outpatient diagnostic test. Therefore, you are responsible to pay the allowed amount of $42.79, which is less than the $50 copayment. 

You received an interrogation device evaluation on November 1, 2020. An interrogation device evaluation is considered an outpatient diagnostic test. Therefore, you are responsible to pay the $50 copayment. 

You received an interrogation device evaluation on December 1, 2020. An interrogation device evaluation is considered an outpatient diagnostic test. Therefore, you are responsible to pay the $50 copayment.

The total amount you owe is: $142.79.

You have been asked to pay the total copayment amount of $142.79 for interrogation device evaluations. Interrogation device evaluations 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 copayments for interrogation device evaluations provided from October 21, 2020, to December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on March 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's facility failed to obtain prior authorization. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. 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 wound care provided on March 8, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 6, 2020.
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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the neuromuscular stimulator rendered on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided by a participating provider on December 30, 2020.

You asked the Plan to waive the copayment for a duplex scan. You say that you do not agree with this copayment. 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 $110 copayment for outpatient diagnostic tests/in-network/radiological diagnostic services. 

You have been asked to pay a $110 copayment for duplex scan. A duplex scan falls within the outpatient diagnostic tests/in-network/radiological diagnostic services 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 a duplex scan provided by a participating provider on December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the office visit you had with a pulmonologist and the respiratory flow volume loop test you had on September 18, 2020.
You asked the Plan to waive the cost sharing for the office visit and the diagnostic test. You say that you do not agree with the amount being charged. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the diagnostic test, the allowed amount ($41.51) is less than your copayment responsibility, so you are responsible for the full allowed amount for the test.
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 specialist visits and a $50 copayment for diagnostic tests.
You have been asked to pay a $40 copayment for the office visit and a $50 copayment for the diagnostic test. 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 sharing for the office visit you had with a pulmonologist and the respiratory flow volume loop test you had on September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lipid testing rendered on January 7, 2021.

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 services are not covered.

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, a lipid panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lipid testing rendered on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 11, 2021.

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 services are not covered.

The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under code 81455 are not covered. 

We looked at the file and Medicare rules. The file shows that the services at issue were billed with code 81455. 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 pay for the laboratory services rendered on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the arthrocentesis provided on January 26, 2021.

You asked the Plan to waive the deductible for the arthrocentesis. You say that the claim and bill would not have happened if COVID had not interfered with scheduling. You say that you are requesting insurance pay the bill. The Plan denied your request. The Plan says the deductible applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $203. This is the amount you have to pay out-of-pocket before the Plan will pay its share for your covered Medicare Part A and B services.

The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $203 deductible applies to physician services. This cost sharing is a contractual obligation that had not been met at the time the arthrocentesis was received on January 26, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the arthrocentesis provided on January 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cystometrogram provided by an out-of-network provider on February 22, 2021.
You asked the Plan to pay for the cystometrogram. You say that the patient had a complex problem requiring surgery or treatment and was referred by their primary care physician for consultation. You say that the practice was one of the only gynecologic oncology offices in the area at the time of service and the claim should be reprocessed for payment. The Plan denied your request. The Plan says the non-emergent 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 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 cystometrogram provided by an out-of-network provider on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Deceli portable mini exercise bike (A9300) purchased December 8, 2020.

You asked the Plan to pay for the exercise bike. You say that you are seeking reimbursement. You were told as of January 1, 2021 the cost of home gym equipment can be submitted for reimbursement for the wallet benefit. The Plan denied your request. The Plan says exercise equipment is not covered. The provider also is not a participating eligible Medicare provider.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the Deceli portable mini exercise bike (A9300) purchased December 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have waive the copayment charged for ambulance transport.

You asked the Plan to waive this copayment. You do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement.

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 $265 copayment for ambulance transport. 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 this copayment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0483) provided on April 21, 2020, by an out of network (OON) provider.
You asked the Plan to pay for a drug test. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a drug test (G0483) provided on April 21, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested device is not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a home ventilator. Our reviewer says that the documentation does not support that the requested ventilator is medically reasonable or necessary. Our physician reviewer found you have a diagnosis of Chronic obstructive pulmonary disease (COPD), although the records do not provide results of pulmonary function testing to confirm this. There is no arterial blood gases test to confirm Carbon dioxide retention.
Medicare does not cover a ventilator when used as Bilevel Positive Airway Pressure (BiPAP), as it is here. Certain BiPAP devices can provide the average volume-assured pressure support (AVAPS) mode of support, at less cost. There is no documentation of BiPAP failure. Therefore, you do not meet criteria for the requested device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. You say that the requested Aranesp is medically necessary. The Plan denied your request. The Plan says Aranesp is not covered under the enrollee's Medicare Part B benefit when dispensed by a retail pharmacy and self-administered at home. The Plan says they have approved Aranesp under the enrollee's Medicare Part D benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Aranesp.

Benefits for Aranesp may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid, digital, binaural, CIC (V5258), rendered by non-contracted provider, Eargo Hearing Inc, on February 17, 2021.

You asked the Plan to pay for hearing aid, digital, binaural, CIC (V5258), rendered by non-contracted provider, Eargo Hearing Inc, on February 17, 2021. You say that the Plan should cover this hearing aid and services. The Plan denied your request. The Plan says hearing aids purchased via the internet are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract clearly states internet hearing aid purchases are not covered. You did not follow your Plan contract rules when making this purchase. Therefore, we decided that the Plan does not have to pay for hearing aid, digital, binaural, CIC (V5258), rendered by non-contracted provider, Eargo Hearing Inc, on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker provided on June 26, 2020.
You asked the Plan to pay for walker. You say that this walker meets the criteria for durable medical equipment and was medically necessary for you. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this provider is not enrolled in the Medicare program and is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that a provider or supplier must be enrolled in the Medicare program to be eligible for payment. We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not payable. Based on this information, we decided that Medicare rules for coverage of walker have not been met. Therefore, we decided that the Plan does not have to pay for a walker provided on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam image capture (D0364), apicoectomy procedures (D3410, D3425) and three retrograde fillings (D3420) provided on December 18, 2020.
You asked the Plan to pay for the dental services. You say that these services were necessary to save your teeth. The Plan denied your request. The Plan says these services are not covered by your dental 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 pay for a cone
beam image capture (D0364), apicoectomy procedures (D3410, D3425) and three retrograde fillings (D3420) provided on December 18, 2020.