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

We decided that the Plan does not have to waive the copayments for wound debridement provided from April 3, 2019 to June 12, 2019.
You asked the Plan to waive the copayments for wound debridement. You say that you disagree with the charges and were not informed how high they would be. 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 $300 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received wound debridement from April 3, 2019 to June 12, 2019 for a total of 10 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. You have been asked to pay the allowed amount of $2,918.60, which is less than the total copayment amount for wound debridement. Wound debridement falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 wound debridement provided from April 3, 2019 to June 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on November 30, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges. 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 $250 copayment for diagnostic radiology services. You have been asked to pay the allowed amount of $136.44, which is less than the $250 copayment for a CT scan. A 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 waive the copayment for a computed tomography (CT) scan provided on November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on October 22, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation did not include a physician order or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. There is no evidence that shows the test was individualized to identify 22 or more specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external ambulatory infusion pump, insulin.You asked the Plan to pre-approve an external ambulatory infusion pump, insulin (E0784). You say that the enrollee needs an insulin infusion pump. The Plan denied your request. The Plan says the medical records indicate dosage adjustments have only been done by the provider at appointments. The Plan must follow Medicare rules. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning ofa malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.We looked at the file and Medicare rules. The enrollee does not meet the requirement of insulin dose self-adjustments. Based on this information, we decided that Medicare rules for coverage of an external ambulatory infusion pump, insulin (E0784) have not been met.Therefore, we decided that the Plan does not have to pre-approve an external ambulatory infusion pump, insulin.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair repairs.
You asked the Plan to pre-approve power wheelchair repairs. You say that your knees are getting worse and you want to use your power wheelchair more but it needs repair. The Plan denied your request. The Plan says the documentation submitted does not show a medical need for a power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve additional routine transportation (108 one-way trips).
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that the enrollee has exhausted their transportation benefit for the 2020 calendar year.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the plan has not provided us any evidence that you have exhausted your yearly allowance for routine transportation trip coverage. The Plan documents in the case file that they do not have a trip log available to provide us. This means that the plan has not substantiated their denial reason or supported their decision. Records from the Plan's transportation provider are considered to be within the control of the plan. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control. Therefore, we decided that the Plan has to pre-approve additional routine transportation (108 one-way trips).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from December 16, 2019 to January 14, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that there was no daily skilled nurse or therapist need.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from December 16, 2019 to January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided from November 27, 2019 through December 5, 2019.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that submitted your bill for review. You say that this should be covered under the skilled nursing benefit. 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 $300 copayment per day for days 1-5 and a $0 copayment per day for additional days for each in-network, Medicare-covered inpatient hospital stays. You have been asked to pay a $1,500 copayment for the inpatient rehabilitation stay. ($300/day x 5 days = $1,500). The inpatient rehabilitation 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 rehabilitation stay provided from November 27, 2019 through December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the rendering provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 lab work provided on December 17, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that even though you did not use the ambulance to go to the hospital on the date of service, you did end up going to the hospital by ambulance the following morning. You say that you had no idea that the first ambulance call would not be covered by the Plan and the ambulance responders said nothing about the possibility of it. You stated that if they had, you probably would have gone to the hospital at that time. You say that because you were ill and your ability to make clear decisions was impaired, you believe the Plan should provide coverage. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 26, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the drainage of a skin abscess provided on October 31, 2019 and December 12, 2019. You asked the Plan to waive the copayments for the drainage of a skin abscess. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The enrollee received the drainage of a skin abscess on October 31, 2019. Therefore, you are responsible to pay the allowed amount of $141.40, which is less than the $200 copayment. The enrollee received the drainage of a skin abscess on December 12, 2019. Therefore, you are responsible to pay the allowed amount of $141.40, which is less than the $200 copayment. The total amount you owe is: $282.80. The enrollee has been asked to pay the total copayment amount of $282.80 for the drainage of a skin abscess. The drainage of a skin abscess falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided the Plan does not have to waive the copayments for the drainage of a skin abscess provided on October 31, 2019 and December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 13, 2019 to January 8, 2020 by a non-Medicare participating provider.
You asked the Plan to pay for these services. You say that you feel you should be reimbursed for these services. The Plan denied your request. The Plan says the services received are not a covered benefit.
Medicare rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. Review of the file shows that the provider did not participate with Medicare. 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 November 13, 2019 to January 8, 2020 by a non-Medicare participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF services.
You asked the Plan to pre-approve the continued SNF services. You say that the enrollee has an opened wound
that needs to be kept clean. You also say that the enrollee needs to remain in a SNF until having surgery. The
Plan denied your request. The Plan says SNF care beyond 100 days per benefit period is not covered by
Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that the enrollee received 100 days of SNF care during the benefit period from April 25, 2020.
The Plan has covered 100 days of SNF care.
Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pre-approve continued SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
You asked the Plan to pre-approve PET scan. You say that you feel that the enrollee is an ideal candidate for this treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this PET scan is not recommended for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 PET scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested PET scan. Our physician reviewer found the requested PET scan is not medically reasonable and necessary in order to confirm the presence of this type of tumor prior to the proposed Lutathera treatment. The medical necessity of the proposed Luthatera treatment cannot be affirmed given the records submitted. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker purchased on December 26, 2019.
You asked the Plan to pay for the walker. The Plan denied your request. The Plan says that the provider is not
certified for Medicare and therefore, is not a Medicare-Certified provider.
The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who
is not enrolled in the Medicare Program.
The purchase was not made with a supplier who is enrolled in the Medicare program. Therefore, we decided
that the Plan does not have to pay for the walker purchased on December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7311).
You asked the Plan to pre-approve alveoloplasty in conjunction with extractions. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested dental services are not covered by Medicare or the 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. Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7311).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost of hearing aids (V5261) provided on November 19, 2019.You asked the Plan to pay the full cost of hearing aids. You say that you cannot afford this bill.The Plan denied your request. The Plan says this processed correctly.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 covers hearing aids up to a $1200 maximum benefit every four years for hearing aids with a 20% coinsurance. We looked at the file and the Plan's rules. The file shows that you have been asked to pay 20% of the $1,200 benefit ($240) and the amount that exceeds that benefit ($2,348). Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met.Therefore, we decided that the Plan does not have to pay the full cost of hearing aids (V5261) provided on November 19, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visual field assessment with concurrent real time data to be provided by an out of network provider.You asked the Plan to pre-approve Foresee Home (0379T). You say that Medicare covers this procedure.The Plan denied your request. The Plan says this procedure is considered investigational/experimental at this time and the provider is not in network.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of visual field assessment with concurrent real time data (0379T) have not been met.Therefore, we decided that the Plan does not have to pre-approve visual field assessment with concurrent real time data to be provided by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 13, 2019.
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. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 September 13,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective coating (V2750), lens sphcy trifocal 4.0/.12-
(V2303) and frames (V2020) purchased on October 1, 2019.
You asked the Plan to pay for the eyewear. You say that the book says up to $125 for one pair of eye wear per
calendar year and the Plan only paid $100. The Plan denied your request. The Plan says you exhausted your
benefit allowance.
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.
We looked at the file and the Plan's rules. The $100 eyewear allowance was exhausted with this total purchase
of $379 as it was specifically applied to your eyeglass frames (V2020). Therefore, the remaining amount of
$279.00 was charged at the time of service. Your EOC states, for Centennial or Vital plan members, if the
eyewear you purchase costs more than $100, you pay the difference. Therefore, we decided that the Plan does
not have to pay for anti-reflective coating (V2750), lens sphcy trifocal 4.0/.12- (V2303) and frames (V2020)
purchased on October 1, 2019.