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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 24, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you only received a tetanus shot. 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 $110 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $110 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services during your emergency room visit.
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 emergency room visit provided on September 24, 2019.
Your complaint about the long wait time 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 the ultrasound provided on September 12, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you already paid your specialist copayment. You say that you cannot afford this high copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $122.62, which is less than the standard $250 copayment for the ultrasound. The ultrasound 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 the ultrasound provided on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 29, 2018 to September 21, 2018 by an out of network (OON), international provider.
You asked the Plan to pay for the X-Rays, surgery and durable medical equipment. You say that this should be reimbursed because the services were related to a major procedure, and necessary diagnostic pre-surgery and post-surgery services. The Plan denied your request. The Plan says when you are outside the service area and cannot get care from a network provider, only urgently needed services are covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 29, 2018 to September 21, 2018 by an out of network (OON), international provider. Your complaint about receiving incorrect information 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Fitbit.
You asked the Plan to pre-approve the requested item. You say that the item will encourage you to exercise to reduce chronic pain. The Plan denied your request. The Plan says a fitness wearable item is not a covered item of Medicare or your plan.
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 pre-approve a Fitbit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 28, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says any and all codes on this claim are denied, and in addition, previous payments to these providers for this enrollee are subject to recoupment.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 18, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was only a medication check and were done in five minutes. You say that this shouldn't pull a copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for a follow up of a pericardial effusion and review of the echocardiogram results. 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 office visit provided on September 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance services provided to the enrollee on August 15, 2019.
You asked the Plan to pay for these services. You say that you had no choice but to use an air ambulance to get your husband from Iowa to Texas safely. The Plan denied your request. The Plan says that non-emergency transportation by ambulance is appropriate if it is documented that the member's condition is such that other means of transportation could endanger the person's health and that transportation by ambulance is medically required.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 these services. Our reviewer says that air ambulance services were not medically reasonable and necessary for the enrollee in this case. There is no evidence that the enrollee was in need of services that were not available in Iowa. Therefore, the transfer to the Texas is not shown to have been medically necessary. Relocation based on patient or family preference is not considered a medical issue. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for air ambulance 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 pay for the air ambulance services provided to the enrollee on August 15, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Suparts FX.
You asked the Plan to pre-approve Suparts FX. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried Monovisc and Orthovisc as required by step therapy rules.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Suparts FX. Our reviewer says that the criteria for coverage of Suparts FX have not been met. Our physician reviewer found the Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Supartz FX. The provided medical records do not indicate that the patient has tried and failed the required drugs or that the required drugs would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Suparts FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Suparts FX.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis from Advanced Pain Management and Rehabilitation.
You asked the Plan to pre-approve a knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (L1843). You say that the knee orthosis is medically necessary The Plan denied your request. The Plan says the knee orthosis is not 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 a knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (L1843). Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage of knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (L1843). The medical records document that there is no instability of the right knee. There has not been any recent injury or surgical procedure. The requested knee orthosis is not medically reasonable and necessary. 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 knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (L1843) have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis from Advanced Pain Management and Rehabilitation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and cystoscopy provided on July 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says that the services were not urgent or emergent. The Plan also says the services can be provided in 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 the office visit and cystoscopy provided on July 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says with the information provided, it cannot be determined how the member came to the servicing provider.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not contain medical records. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network specialists available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician).
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 pay for drug testing services provided to the enrollee on September 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 23, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you believe the provider billed the ultrasound incorrectly. You say it is unclear if the thyroid was included in the head and neck ultrasound. 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 $250 copayment per day for Medicare-covered diagnostic radiology services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for ultrasounds.
You have been asked to pay a $137.01 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were charged with code 76536 which is for an ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation.
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 ultrasound provided on October 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on July 10, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you had no idea that the ultrasound would be $100. You say you cannot afford this and would not have had it done unless it was an emergency. 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 $100 copayment per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound 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 the ultrasound provided on July 10, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on May 23, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you shouldn't have to pay a copayment twice for getting your finger wrapped. 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 $110 for each Medicare-covered emergency room visit. You have been asked to pay a $110 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the ED. 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 ED visit provided on May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you have used this doctor before. You say that you trust him. The Plan denied your request. 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to you, an out-of-network provider, for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is a network lock-in, and medically necessary care is available in 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. You are not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to you, an out-of-network provider, for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on September 24, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that this was a necessary procedure. You say that you were informed you did not have a copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility for outpatient surgery. You have been asked to pay a $275 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a surgical procedure. 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 endoscopy provided on September 24, 2019.