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

We decided that the Plan does not have to waive the copayments for a specialist visit and an MRI and does not have to waive the coinsurance for a Medicare Part B drug injection
You asked the Plan to waive the copayments for a specialist visit and an MRI and to waive the coinsurance for a Medicare Part B drug injection. 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 $25 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $175 copayment for diagnostic radiology other than CT scans. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You had a specialist visit on October 2, 2019. Therefore, you are responsible to pay the $25 copayment. You received a Medicare Part B drug on October 2, 2019. The allowed amount is $11.93 and 20% of that is $2.39. You received an MRI on October 12, 2019. Therefore, you are responsible to pay the $175 copayment. The total amount you owe is: $202.39.
You have been asked to pay the total amount of $202.39 for a specialist visit, an MRI and a Medicare Part B drug injection. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An MRI outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 a specialist visit and an MRI and does not have to waive the coinsurance for a Medicare Part B drug injection
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services
You asked the Plan to pay for surgical assistant services. You say that your provider was requested to assist in this enrollee's surgery by the treating physician. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the records show that the provider did not perform these services.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the Plan sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The documentation submitted does not support payment of this claim as billed. The record does not show that the provider provided assistant at surgery services for this procedure. Therefore, you have not furnished sufficient information to the Plan to justify payment of this claim. Based on this information, we decided that Medicare rules for coverage of surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 18, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on August 17, 2017. These orthoses are still within
the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient mental health care services after March 5, 2020.
You asked the Plan to pre-approve continued inpatient mental health care services after March 5, 2020. You say that the requested continuation of inpatient mental health care services is medically necessary. The Plan denied your request. The Plan says that the requested continuation of inpatient mental health care services is not medically necessary.
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, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. 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 continued inpatient mental health care services after March 5, 2020.
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: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the walking boot. We decided that the Plan does not have to waive the coinsurance for the walking boot. 

You asked the Plan to waive the coinsurance for the walking boot. You say that you were never told you had to pay for the walking boot. The Plan says that that cover all medically necessary DME covered by Original Medicare.

We decided that the Plan has to adjust the coinsurance for the walking boot. 

The Plan follows Medicare rules. 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 enrollees must pay a 20% coinsurance for durable medical equipment. The amount approved by the Plan for the walking boot was $257.06. 20% of the approved amount for the walking boot equals $51.41. Therefore, we decided that the Plan has to adjust the coinsurance for the walking boot. 

We also decided that the Plan does not have to waive the coinsurance for the walking boot.

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 the walking boot. Therefore, we decided that the Plan does not have to waive the coinsurance for the walking boot.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for a drug test 
You asked the Plan to waive the deductible and copayment for a drug test. You say that you met your yearly deductible and 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. Your contract with the Plan says that there is a $300 deductible. Your contract with the Plan also clearly says that after the $300 deductible has been met, enrollees must pay a $20 copayment for labs. You received a drug test on September 16, 2019. The record shows that you had only paid $58.37 toward the $300 deductible. Therefore, you are responsible to pay the remaining deductible balance of $241.63. Now that the $300 deductible has been met, enrollees are also responsible to pay the $20 copayment. The total amount you owe is: $261.63. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a drug test was received on September 16, 2019. Therefore, we decided that the Plan does not have to waive the deductible and copayment for a drug test
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay the ambulance transports provided on October 4,
2018 and October 15, 2018.
You asked the Plan to waive the copay the ambulance transports. You say that you cannot afford to pay the
cost-sharing. The Plan denied your request. The Plan says that the claims processed 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 $325
copay for each Medicare-covered one-way ambulance trip.
You have been asked to pay a $325 copay for the ambulance transports. The ambulance transports fall within
the Medicare-covered one-way ambulance trip 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
copay the ambulance transports provided on October 4, 2018 and October 15, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monthly rental of the transcutaneous electric nerve stimulator (TENS) provided on October 11, 2019.
You asked the Plan to pay for the monthly rental of the TENS unit. You say that this was billed correctly with the KX modifier. This should be paid as it was billed correctly based on Medicare rules. The Plan denied your request. The Plan says Medicare covers rental of a TENS unit for only two months. The plan paid for the rental from March 11, 2019 to April 11, 2019. Therefore, no further rental payments can be made.
The Plan must follow Medicare rules. Medicare rules say that TENS units are covered on a rental basis for a two-month trial. If this trial is successful, the treating physician may order the TENS unit for purchase. In this case, the documentation shows that the enrollee began her two-month trial in March 2019. She was seen again on April 30, 2019, at which time an order was placed for the purchase of the TENS unit. There is no explanation provided for why the enrollee did not receive the device for purchase, and no evidence that a re-trial would be necessary starting in October. A third month of TENS rental is not in accordance with Medicare rules which require purchase of the device if it is deemed beneficial after the two month rental period. Therefore, we decided that the Plan does not have to pay for the monthly rental of the transcutaneous electric nerve stimulator (TENS) provided on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the FreeStyle Libre continuous glucose monitor (CGM) and supplies provided on October 16, 2019.
You asked the Plan to pay for the CGM and supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. The Plan requested, but did not receive, medical records to show that the enrollee met the coverage criteria. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the FreeStyle Libre continuous glucose monitor (CGM) and supplies provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient skilled nursing care services provided to the enrollee on June 26, 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 provider failed to request authorization before rendering the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 outpatient skilled nursing care services provided to the enrollee on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941) and an office visit (99204).
You asked the Plan to pre-approve these services. You say that you have been diagnosed with bulging discs, Scoliosis and Sciatica. To avoid surgery, you would like to try chiropractic treatment as you have not had any pain relief. The Plan denied your request. The Plan says the medical records provided do not demonstrate subluxation of the spine by x-ray or physical exam. Therefore, you do not meet criteria for coverage of these requested services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, the records provided do not demonstrate subluxation of the spine by x-ray or physical exam. Therefore, we decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941) and an office visit (99204).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits, outpatient therapy services, and X-Ray services provided from June 18, 2019 to August 26, 2019.
You asked the Plan to pay for chiropractic services. You say that according to Medicare guidelines all criteria have been met and these services were medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when furnished by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for office visits, outpatient therapy services, and X-Ray services provided from June 18, 2019 to August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided to you by an out-of-network provider on September 26, 2019.You asked the Plan to pay forthe services. You say that the services were necessary.The Plan denied your request. The Plan says the services were available in-network.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe chiropractic services provided to you by an out-of-network provider on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit and X-Ray examination. You say that this provider has been taking care of you since you were in a motorcycle accident. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
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 December 4, 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 laboratory services rendered to the enrollee on September 30, 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 the services are not payable.
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately payable when furnished in different payment localities. We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different payment localities. 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 to the enrollee on September 30, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus immunization (90715 and 90472) provided on September 17, 2019.
You asked the Plan to pay for the tetanus immunization. You say that you have never had to pay for a tetanus vaccination in the past and believe this should be covered by the Plan. The Plan denied your request. The Plan says the records do not indicate a risk or acute injury justifying coverage under Part B benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus immunization. Therefore, we decided that the Plan does not have to pay for a tetanus immunization (90715 and 90472) provided on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forframes (V2020) progressive lens (V2781) anti-reflective coating (V2750) provided on September 5, 2019.You asked the Plan to pay forthe frames and lenses. You say that you had your exam at a qualified store but chose to get your glasses at a non-qualified place and paid $500. You feel you should be reimbursed because the allowance is a part of your benefits.The Plan denied your request. The Plan says enrollee's must receive their vision services from a participating vision care provider.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 covers these services when provided by a network provider. We looked at the file and the Plan's rules. Services provided by an out of network provider is not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met.Therefore, we decided that the Plan does not have to pay forframes (V2020) progressive lens (V2781) anti-reflective coating (V2750) provided on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 21, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that 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 service 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 laboratory services provided on October 21, 2019.