Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation.

You asked the Plan to pay for the physician service. You say that you did not receive proper notice of the
enrollee's benefit determination. You also say that the physician rendered the service in good faith. The Plan
denied your request. The Plan says Medicare denies a claim if it is not received by the plan within twelve
months or one calendar year from the date when the services were rendered.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the physician service was not filed until September 10, 2020. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the psychiatric diagnostic evaluation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arthroscopy, shoulder, surgical; debridement, limited,
one or two discrete structures (29822), Arthroscopy, Shoulder, Surgical, Distal Claviculectomy Including
Distal Articular Surface (29824) and Arthroscopy, Shoulder, Surgical; With Rotator Cuff Repair (29827) for
the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that records do not show that the enrollee has failed a trial of treatment
given by the doctor for at least three months.

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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. There is no imaging
to support a full-thickness rotator cuff tear for which conservative care might not be indicated prior to surgery.
Documentation is not evident of extenuating circumstances to support surgery prior to reasonable/comprehensive conservative measures. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Arthroscopy, shoulder, surgical; debridement, limited, one or two discrete structures
(29822), Arthroscopy, Shoulder, Surgical, Distal Claviculectomy Including Distal Articular Surface (29824)
and Arthroscopy, Shoulder, Surgical; With Rotator Cuff Repair (29827) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided during your outpatient hospital visit.

You asked the Plan to pay for the self-administered drugs. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says self-administered drugs are not covered under your Medicare Part B benefit.

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 pay for the self-administered drugs provided during your outpatient hospital visit.

Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy.

You asked the Plan to pay for these services. You say that you needed the services due to weight loss from IBS. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes.

Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services.

You asked the Plan to waive the copayment for the outpatient surgical services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $350 copayment for Outpatient surgery.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient surgical services. You have been asked to pay a $215.04 copayment for the outpatient surgical services, which is less than the contracted $350 copayment amount. The outpatient surgical services fall within the Outpatient surgery 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 outpatient surgical services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for unspecified preventative procedure (D1999).

You asked the Plan to pay for unspecified preventative procedure. You say that the service should be covered. The Plan denied your request. The Plan says the services is not a covered benefit under your Plan.

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. Specifically, the service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for unspecified preventative procedure (D1999).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast enlargement with insertion of prosthetic implant.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that you experience significant distress or impairment in social or occupational or other important areas of functioning.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate that breast enlargement with insertion of prosthetic implants is medically reasonable and necessary for the enrollee in this case. The case does not contain photographs. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve breast enlargement with insertion of prosthetic implant.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external electrocardiogram (EKG) recording.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $50 copayment for all other Medicare-covered diagnostic procedures and tests.

Review of the file shows that you received an EKG recording. Per the contract with the Plan, there is a $50 copayment for all other Medicare-covered diagnostic procedures and tests. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $27.01. Given that the allowed amount was less than the $50 copayment, you have been asked to pay $27.01 for these services.

Therefore, we decided that the Plan does not have to waive the copayment for the external electrocardiogram (EKG) recording.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic ultrasonic guidance (76942).

You asked the Plan to waive the copayment for the diagnostic services. You say that CPT code 20550 cannot
be done by the doctor without having the ultrasonic guidance to insert the needle. Therefore, you should only
be responsible for one copayment. The Plan denied your request. The Plan says the claim processed and the
correct copayments were applied per the Evidence of Coverage.

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 $60
copayment for Medicare covered x-rays and ultrasounds.

You have been asked to pay $60 copayment for the diagnostic services. The diagnostic 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 diagnostic ultrasonic guidance (76942).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the hearing aids.

You asked the Plan to reimburse you for these services. You say that you were told that it would be more expensive if you went through the Plan provider. The Plan denied your request. The Plan says services from a non-network provider 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 pays for hearing aids only from a participating provider.

We looked at the file and the Plan's rules. The file shows that you did not purchase hearing aids from the Plan provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to reimburse you for the hearing aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), prophylaxis (D1110) and bitewing radiographic images (X-Ray) (D0172).

You asked the Plan to pay for oral evaluation, prophylaxis and bitewing X-Rays. You say that the services should be covered. The Plan denied your request. The Plan says you received care from an out of network provider, for date of service in the amount of $283. The allowed amount was $134. The applicable $25 copayment was applied, and the claim was paid in the amount of $109. The balance of $149 can be billed by the provider.

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. Specifically, you received care from an out-of-network provider. This means you can be billed higher than you would be if seen by an in-network provider. The Plan allows $134 (what it would have cost if seen by an in-network provider with your $25 copayment) towards the services provided and you are responsible for any cost greater than that. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), prophylaxis (D1110) and bitewing radiographic images (X-Ray) (D0172).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for lumbosacral decompression and fusion Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs.

You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were not told in the
beginning of treatment that you would have a coinsurance. 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 for in-network Medicare-covered Part B chemotherapy drugs and other Part B drugs.

You have been asked to pay a total of $5,337.71 for the chemotherapy drugs. The chemotherapy drugs fall
within the "Medicare Part B prescription drugs" benefit category. See provided chart.

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 chemotherapy drugs.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for eyeglasses (V2299, V2020).

You asked the Plan to pay in full for the eyeglasses. You say that the eyewear should be covered. The Plan denied your request. The Plan says it is only responsible for the $200 allowance provided in the plan contract.

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 only provides a $200 annual allowance towards eyewear. Any amount over this is the enrollee's responsibility.

We looked at the file and the Plan's rules. The plan paid the $200 allowance towards the eyeglasses. The plan is not responsible for the remaining $532 per the plan contract. Therefore, we decided that the Plan does not have to pay in full for eyeglasses (V2299, V2020).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work.

You asked the Plan to waive the copayment for the laboratory work. You say that you were not aware you would be charged a separate copayment for having the laboratory work done on a different day than your annual physical exam. 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 $10 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. 

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory work.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient residential treatment.

You asked the Plan to pay for the inpatient residential treatment. The Plan denied your request. The Plan says enrollees must choose in-network providers except in emergent or urgent care situations.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for inpatient residential treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on September 22, 2020.

You asked the Plan to pay for the device. You say that this should be paid for. The Plan denied your request. The Plan says pneumatic compression devices are covered in the home setting for the treatment of chronic venous insufficiency with venous stasis ulcers or lymphedema

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 pay for the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the pneumatic compression device (E0673, E0675) is not medically necessary. The documentation does not reveal treating medical practitioner progress notes revealing indications or objective physical exam findings of peripheral artery disease or a need for the E0673 and E0675. 

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 device have not been met. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0675) provided to the enrollee on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee from June 18, 2020, through July 30, 2020, by a non-participating provider.

You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the enrollee's visit before providing services to the enrollee as outlined on the enrollee's ID card.

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 the medical services provided to the enrollee from June 18, 2020, through July 30, 2020, by a non-participating provider.