Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression gloves.You askedthe Plan to pre-approve compression gloves. You say that compression gloves are medically necessary.The Plan denied your request. The Plan says that you do not meet criteria for coverage of compression gloves.The Plan must follow Medicare rules. The rules say that Medicare may cover items that meet the definition of DME, surgical dressings, or braces.In this case, the requested compression gloves do not fall into any of these benefit categories. It is a non-reusable supply which is not being used as a dressing over a qualifying wound and is not rigid or semi-rigid. Although this item may be appropriate for you, neither Medicare nor your Plan provides coverage for this
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON surgical services. You say that you don't know of other in-network providers you can see. 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. 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 the surgical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 23, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible charge for the services provided to you on March 24, 2019. 
 
You asked the Plan to waive the deductible. The Plan denied your request. The Plan says the deductible was not met. 
 
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 $1,000 deductible for out-of-network services.  
 
The service you asked the Plan to pay for were provided by an out-of-network provider. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the services were received. Therefore, we decided that the Plan does not have to waive the deductible charge for the services provided to you on March 24, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided June 27, 2019 to June 29, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that prior authorization was not obtained. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was with random chest pain, back pain for one month (Morphine is not helping and requesting Norco), ongoing nausea, vomiting, diarrhea, abdominal pain, leg edema, shortness of breath when ambulating, and dysuria. He has a history of myocardial infarction (MI), alcohol (ETOH) and substance abuse disorder, schizophrenia, seizures, heavy smoker, and pulmonary embolism two months back, and is on Xarelto, but is non-compliant. The enrollee was under hospice for end stage congestive heart failure and "fired them" in April 2019. Out of medication for one month. Does not drink but bought a bottle of ETOH: still feeling suicidal but no self-harm. Member was admitted for diuresis, and restart of Xarelto. His condition stabilized and improved and he was discharged home on 06/29/2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided June 27, 2019 to June 29, 2019. 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: Unfavorable

We decided that the Plan does not have to pre-approve a custom gait belt for the enrollee.You asked the Plan to pre-approve the belt. You say that this is needed to assist the enrollee in transferring, and will be used by the family and physical therapists.The Plandenied your request. The Plan says there is no documentation of why a standard belt is not appropriate.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 the belt. Our reviewer says that the requested belt is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal extenuating factors that indicate that a custom gait belt would be more effective for this enrollee's condition than a standard gait belt. A custom gait belt appears to exceed her medical need and there is no evidence that this is more effective than a standard available medically appropriate non custom gait belt.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 belt have not been met.Therefore, we decided that the Plan does not have to pre-approve a custom gait belt for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alert or alarm device (A9280).
You asked the Plan to pre-approve an alert or alarm device. You say that the enrollee was given a life alert from her previous insurance company. You feel that she should be able to obtain this device due to her various medical conditions. The Plan denied your request. The Plan says this is not a covered benefit.
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 an alert or alarm device (A9280).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 6, 2019 to September 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were not aware of the requirement of obtaining a prior authorization. The Plan denied your request. The Plan says no clinic notes were sent for review.
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 lab services at issue in this appeal. The Plan did not pre-approve the services at issue. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized to identify 22 or more specific non-prescribed medications or illicit substances. 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 lab services provided on September 6, 2019 to September 9, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Gold Bond Ultimate Softening Foot Cream and Sunbeam Universal Humidifier Filter purchased December 22, 2019. 
 
You asked the Plan to pay for the foot cream and humidifier filter. You say that you're getting a hard time because all you have to submit are screenshots showing what you bought, amounts and delivery dates. You have no genuine receipt. The Plan denied your request. The Plan says these items are not covered. The plan has approved reimbursement in the amount of $71.70 for the approved items.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the foot cream and humidifier filter is an OTC item. However, the plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. humidifier filters and non-medicated lotions are not listed as covered items under the plans Flex Benefit. In addition, page 6 of the 2019 Flex Benefit reimbursement lists moisturizers as a non-covered item. Therefore, we decided that the Plan does not have to pay for Gold Bond Ultimate Softening Foot Cream and Sunbeam Universal Humidifier Filter purchased December 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion of normal saline solution provided on January 14, 2020 and January 17, 2020.
You asked the Plan to waive the coinsurance for the infusions. The Plan denied your request. The Plan says that you must pay 20% coinsurance for each Medicare-covered Part B drug.
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 each Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the infusions. The infusions fall within the Medicare-covered Part B drug 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 infusion of normal saline solution provided on January 14, 2020 and January 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a mammogram (77065, G0279) and an ultrasound (87642) provided January 15, 2020. 
 
You asked the Plan to waive the copayments for the mammogram and the ultrasound. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were charged as the deductible was not yet met. 
 
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 for in-network services.  
 
The item or service you asked the Plan to waive the copayments for were in-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for in-network services. This cost sharing is a contractual obligation that had not been met at the time the mammogram and the ultrasound was received on January 15, 2020. Therefore, we decided that the Plan does not have to waive the copayments for a mammogram (77065, G0279) and an ultrasound (87642) provided January 15, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 6, 2019 by an out of network provider. 
 
You asked the Plan to pay for the medical services. You say that the service was medically necessary. The Plan denied your request. The Plan says you did not request prior authorization. 
 
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 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 the medical services provided on December 6, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased on October 22, 2019 from a non-Medicare provider.You asked the Plan to pay for the DME. You say that you were told you would be reimbursed and had no way to know the provider was not a certified Medicare provider.The Plan denied your request. The Plan says this provider does not participate with Medicare. The plan states on October 18, 2019 you called customer service and were advised this service was not a covered benefit and that you would not be reimbursed.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The provider must be eligible to participate in Medicare. The provider the enrollee purchased DME from is not certified for Medicare and therefore, is not a Medicare-Certified provider.Therefore, we decided that the Plan does not have to pay for the DME purchased on October 22, 2019 from a non-Medicare provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on March 4, 2019. 
 
You asked the Plan to pay for the hearing aids. You say that you are entitled to a $4,000 reimbursement for hearing aids. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance. 
 
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.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. You exhausted your $1,000 maximum benefit allowance. The Plan reimbursed you $1,000 and you are responsible for the remainder of the cost. Your EOC states, you have a $1,000 allowance (both ears combined) for hearing aids every year. You are responsible for any amount above the hearing aid coverage limit. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on March 4, 2019.
Appeal type: Practitioner Services
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 from July 2, 2019, to July 10, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 from July 2, 2019, to July 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care (99306), the subsequent nursing facility care (99309, 99308), and the prolonged inpatient service (99356) provided by the out of network (OON) providers from September 27, 2019 to October 10, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by out of network providers, without prior authorization.
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 providers in this case are not network providers 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 initial nursing facility care (99306), the subsequent nursing facility care (99309, 99308), and the prolonged inpatient service (99356) provided by the out of network (OON) providers from September 27, 2019 to October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP supplies provided on January 16, 2019 to April 17, 2019 by an out of network provider. You asked the Plan to pay for the CPAP supplies. You say that the Plan should pay these claims. The Plan denied your request. The Plan says you did not request prior authorization. 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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the CPAP supplies provided on January 16, 2019 to April 17, 2019 by an out of network.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the iron infusions provided on December 17, 2019 and December 26, 2019 You asked the Plan to reduce the coinsurance for the iron infusions. You say that you say you are being charged twice as much for the iron infusion.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 20% coinsurance for each Medicare-covered Part B drug obtained in an in-network provider's office or in-network outpatient setting. You have been asked to pay $156.71 which is 20% of the allowed amount for each of the iron infusions. The allowed amount is $783.55. ($783.55 x 20% = $1567.71). ($156.71 + $156.71 = $313.42). The iron infusions fall 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 reduce the coinsurance for the iron infusions provided on December 17, 2019 and December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKerecisOmega3 and the associated application of the product (Q4158, 15271).You asked the Plan to pre-approve Kerecis Omega3 and the associated application of the product. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 Kerecis Omega3 and the associated application of the product. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the Kerecis Omega3 skin substitute is not medically reasonable and necessary for the enrollee's condition as there is no evidence of underlying diabetes or venous insufficiency and the wound is improving with less than 6 weeks of treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kerecis Omega3 and the associated application of the product have not been met.Therefore, we decided that the Plan does not have to pre-approve Kerecis Omega3 and the associated application of the product (Q4158, 15271).