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

We decided that the Plan does not have to pay for a drug test provided on November 20, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 drug test. 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 a drug test provided on November 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from January 8, 2020 through January 10, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted for two days. You say that it was not for observation. 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 $85 for each visit to an emergency room. You have been asked to pay an $85 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were admitted to outpatient observation. 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 ER visit provided from January 8, 2020 through January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit (99204) provided on November 1, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee had an urgent care visit on November 1, 2019. The Plan states the correct copayment has applied per the enrollee's 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for Urgently needed services. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee had an urgent care visit on November 1, 2019. The enrollee has been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the Urgently needed services 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. Furthermore, CPT code S9083 was denied by the Plan as provider liability. The enrollee is not financially responsible for the amount billed for CPT code S9083. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit (99204) provided on November 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluticasone/salmeterol 100-50 mgc/dose disk with device 14 each blist pack, atorvastatin tablet, carvedilol tablet, furosemide tablet, hydralazine tablet, and mupirocin 2% ointment provided from April 4, 2019 to April 6, 2019.
You asked the Plan to pay for the fluticasone/salmeterol 100-50 mgc/dose disk with device 14 each blist pack, atorvastatin tablet, carvedilol tablet, furosemide tablet, hydralazine tablet, and mupirocin 2% ointment. You say that you had no control over the medications given to you while you were in the emergency room. The Plan denied your request. The Plan says these drugs are not covered by your plan.
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 fluticasone/salmeterol 100-50 mgc/dose disk with device 14 each blist pack, atorvastatin tablet, carvedilol tablet, furosemide tablet, hydralazine tablet, and mupirocin 2% ointment provided from April 4, 2019 to April 6, 2019.
Benefits for fluticasone/salmeterol 100-50 mgc/dose disk with device 14 each blist pack, atorvastatin tablet, carvedilol tablet, furosemide tablet, hydralazine tablet, and mupirocin 2% ointment 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 5, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted did not include a physician order, lab requisition, or medical records supporting the billed test.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab testing billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Zoster (shingles) vaccine provided on December 18, 2019.
You asked the Plan to pay for shingles vaccination. You say that this vaccine was recommended for you, and if you contract the disease it could ravage your body. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this immunization is not covered by Medicare Part B and the Plan does not administer your Medicare Part D prescription drug benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide shingles vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to shingles vaccination. Therefore, we decided that the Plan does not have to pay for Zoster (shingles) vaccine provided on December 18, 2019.
Benefits for shingles vaccination 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diagnostic test (92136) provided on November 25, 2019.
You asked the Plan to waive the coinsurance for the diagnostic test. 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 an outpatient diagnostic test on the date of service at issue in this appeal. The Plan states the correct coinsurance 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 20% coinsurance for all other diagnostic and nuclear medicine radiological services. We looked at the file, the Plan contract and Medicare rules. The file shows you received a diagnostic test on November 25, 2019. You have been asked to pay a 20% coinsurance for the diagnostic test, total $14.82. The diagnostic test falls within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the diagnostic test (92136) provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy services provided on November 21, 2019.
You asked the Plan to waive the copayment for the endoscopy 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 had endoscopy services provided in an ambulatory surgical center 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 $275 copayment for Outpatient surgery provided in an ambulatory surgical center. We looked at the file, the Plan's contract and Medicare rules. The file shows you received endoscopy services performed in an ambulatory surgical center on November 21, 2019. You have been asked to pay a $275 copayment for the endoscopy services. The endoscopy 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 endoscopy services provided on November 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the colonoscopy with biopsy provided on January 3, 2020.
You asked the Plan to waive the deductible for the colonoscopy with biopsy. You say that you were not aware what you could be responsible for with a diagnostic colonoscopy. You say that if you were aware you would not have had the procedure. 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 $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Outpatient surgery is not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy with biopsy was received on January 3, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the colonoscopy with biopsy provided on January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an assistive listening device accessory (charging unit) provided on November 25, 2019.
You asked the Plan to pay for charging unit. You say that these hearing aids are unusable without the charging unit, and you verified with the Plan that there were no restrictions for the purchase of these hearing aids. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this device is not covered by the Plan.
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 2 hearing aids every 36 months; however, the Plan does not cover a charging unit accessory. We looked at the file and the Plan's rules. This charging unit is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for an assistive listening device accessory (charging unit) provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee braces (L1845).
You asked the Plan to pre-approve the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that for coverage criteria to be met knee instability must be documented by examination of the beneficiary and objective description of joint laxity. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the documentation does not show medical necessity. Our physician reviewer found the records indicate the enrollee has a stable knee and moderate arthritis. There is no instability or indication for a knee brace at this time. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve knee braces (L1845).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from July 16, 2019 to July 19, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are disputing the charges for the knee surgery. 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 $185 copayment per day, days 1-7 for each Medicare-covered hospital stay. You have been asked to pay a $185 copayment for each day of the inpatient hospital stay. ($185 x 3 days = $555). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from July 16, 2019 to July 19, 2019.
Your complaint about getting an infection 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility stay from August 5, 2019 to August 31, 2019.
You asked the Plan to waive the copayment for the skilled nursing facility stay. 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 skilled nursing facility care from August 5, 2019 to August 31, 2019. The Plan states 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 $0 copayment per day for days 1-20 and a $50 copayment per day for days 21-100 for Skilled nursing facility care. We looked at the file, the Plan contract and Medicare rules. The file shows that you received skilled nursing facility care from August 5, 2019 to August 31, 2019. You have been asked to pay a $0 copayment per day for days 1-20 and a $50 copayment per day for days 21-27, totaling $350 for dates of service August 5, 2019 to August 31, 2019. The skilled nursing facility stay falls within the Skilled nursing facility 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 skilled nursing facility stay from August 5, 2019 to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit consult to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit consult. You say that you would just like a consult with this doctor to make sure everything that can be done is being done. The Plan denied your request. The Plan says there are in-network providers available for 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 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. Please contact the Plan for a list of in-network providers available. 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 an office visit consult 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 pay for the chiropractic services provided on June 15, 2019 to July 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 chiropractic services provided on June 15, 2019 to July 20, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound services provided on August 30, 2019.
You asked the Plan to waive the copayment for the ultrasound 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 an ultrasound provided in a hospital setting on the date of service at issue in this appeal. The Plan states 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 $125 copayment for other diagnostic procedures and tests provided at any location other than a physician's office. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ultrasound services provided in a hospital setting on August 30, 2019. You have been asked to pay a $102.96 copayment for the ultrasound services, which is less than the $125 contracted amount. The ultrasound services fall within the Outpatient diagnostic tests 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 services provided on August 30, 2019.