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, X-rays, and does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 12, 2020.
You asked the Plan to waive the copayments for a specialist visit, X-rays, and to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the charges because you have never been charged that much in the past. 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 $35 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $20 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a specialist visit on August 12, 2020. Therefore, you are responsible to pay the $35 copayment. You received two X-rays on April 12, 2020. Therefore, you are responsible to pay a $20 copayment per each X-ray. The total amount you owe for X-rays is $40. You received a Medicare Part B drug injection on April 12, 2020. The allowed amount is 14.82 and 20% of that is $2.96.
The total amount you owe is: $77.96. You have been asked to pay the total amount of $77.96 for a specialist visit, X-rays, and a Medicare Part B drug injection. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug injection Medicare Part B prescription drugs benefit category 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, X-rays, and does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating provider on October 7, 2019,to November 11, 2019.You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.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 30% coinsurance for outpatient surgery/out of network. You have been asked to pay a 30% coinsurance of the allowed amount for an outpatient surgery. The total allowed coinsurance is $586.70. The total amount you are being asked to pay is $176 (586.70 x 30% = $176). An outpatient surgery falls within the outpatient surgery/out of network 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 an outpatient surgery provided by a participating provider on October 7, 2019, to November 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean additional ten physical therapy visits for the enrollee.You asked the Planto pre-approvethe additional visits. You say that this is medically necessary.The Plandenied your request. The Plansaysthere does not seem to be a potential to improve.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found further therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. The enrollee appears to be declining with regard to ambulation despite therapy. Gait training is not considered reasonable and necessary when the enrollee's walking ability is not expected to improve.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 additional visits have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean additional ten physical therapy visits for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit to be provided by a tertiary provider.
You asked the Plan to pre-approve the office visit. You say that this appointment is for your yearly follow up visit. You have been under the care of this urologist for 10 years. The Plan denied your request. The Plan says the records do not show that these services cannot be done at a community level. The plan has approved office consultation and follow visits to be done with community level provider.
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 provider at issue in this case is not a network provider with the Plan. 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 office visit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the prostate evaluation at a tertiary care center is not reasonable and necessary for this enrollee at this time. The plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to a community based provider or PCP. The plan is offering the standard of care for the treatment of the enrollee's condition. Routine management of BPH does not require care by a tertiary urologist and can often be managed by primary care physician. 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 office visit have not been met.
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 the office visit. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit to be provided by a tertiary provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on June 8, 2020 and June 15, 2020. You asked the Plan to waive the copayment for wound debridement. You say that you had a negative outcome including significant medical problems and the need for home health services. You say that you shouldn't be responsible for any copayments for that period of time. The Plan denied your request. The Plan says the copayments 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 $250 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $250 copayment for each wound debridement visit. The total amount you owe is $500 ($250/visit x 2 visits = $500). Wound debridement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that wound debridement was provided. 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 wound debridement provided June 8, 2020 and June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the claim was denied as a duplicate in error. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the pelvis.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has hip pain and osteoarthritis. Magnetic resonance imaging (MRI) was ordered but the order expired. A CT scan with contrast has been ordered. The CT scan is not appropriate and not reasonable or medically necessary over the previously ordered MRI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe upper partial denture (D5211) provided on July 21, 2020.You asked the Plan to pay forthe dental item. You say that all of your dental work has been a result of a car crash a few years ago. You say that your tooth broke off at the gum line which changed how your partial denture would be anchored. You also say that you needed a new tooth.The Plan denied your request. The Plan says dentures are limited to 1 set every 5 years. The Plan also says that the frequency limit has been exceeded.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 frequency limit of 1 set of dentures every 5 years has been exceeded.The record shows that the Plan paid for an upper partial denture that you received on March 5, 2019.Therefore, we decided that the Plan does not have to pay forthe upper partial denture (D5211) provided on July 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment purchased on July 30, 2020.
You asked the Plan to pay for the oxygen equipment. You say that renting oxygen equipment on a monthly basis is not a viable option. The Plan denied your request. The Plan says that authorization was not obtained.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for the oxygen equipment purchased on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new prosthesis (K3 identified with code L5980 Flex Foot system).
You asked the Plan to pre-approve a new prosthesis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a K3 prosthesis is only covered for certain indications. 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 new prosthesis. Our reviewer says that the documentation does not support that the requested new prosthesis is medically reasonable or necessary. Our physician reviewer found your current prosthesis is about four years old. You have lost a lot of weight and feel your left leg does not have a good interface with your prosthesis. The documentation supports that you are a K2 ambulatory. Therefore, you do not meet criteria for the requested K3 prosthesis. 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 new prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a new prosthesis (K3 identified with code L5980 Flex Foot system).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5226) and a maxillary immediate denture (D5130).
You asked the Plan to pre-approve the mandibular partial denture and maxillary immediate denture. The Plan denied your request. The Plan says these services are not covered benefits.
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 a mandibular partial denture (D5226) and a maxillary immediate denture (D5130).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay fo rlaboratory testing. You say that this testing is covered by Medicare and should be paid by the Plan.The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.

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 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveposterior inter-spinous decompression spacer.You asked the Plan to pre-approveposterior inter-spinous decompression spacer. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested servicesare not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve posterior inter-spinous decompression spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis. The requested spacer remains experimental for the treatment of spinal stenosis. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 posterior inter-spinous decompression spacer have not been met.Therefore, we decided that the Plan does not have to pre-approveposterior inter-spinous decompression space
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) and extraction (D7210) of tooth #21 provided on July 30, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation and extraction. You say that these services were due to an extenuating circumstance, and you believe they should be covered.The Plan denied your request. The Plan says the problem focused limited oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that the extraction procedure code is not eligible because you previously received an extraction of tooth #21 on April 29, 2013.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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on July 30, 2020 by another provider, and your problem focused limited oral evaluation (D0140) benefit has been exhausted. The Plan contract also says that extractions (D7210) are limited to one procedure per tooth per lifetime of the member. The record shows that you received an extraction of tooth #21 on April 29, 2013, and your extractions benefit for tooth #21 has been exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) and extraction (D7210) of tooth #21 provided on July 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from September 30, 2019, to October 3, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you had bleeding after a surgical procedure and feel that for this reason you should not be responsible for 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 $300 copayment for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from September 30, 2019, to October 3, 2019. Therefore, you are responsible to pay a $300 copayment for days 1-3 (September 30, 2019, to October 2, 2019). $300 (copayment) x 3 (inpatient days) = $900.You have been asked to pay the total copayment amount of $900 for an inpatient hospital stay. An 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 foran inpatient hospital stay from September 30, 2019, to October 3, 2019.