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

We decided that the Plan does not have to pay for ankle braces (L1971) provided on January 22, 2020. 
 
You asked the Plan to pay for the ankle braces. You say that you would like reconsideration because the ankle braces are medically necessary. The Plan denied your request. The Plan says the documentation submitted does not indicate that the provider discussed the need for the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ankle braces have not been met. Specifically, the record indicates that the Plan requested progress notes to indicate the provider discussed the need for the billed supply code along with documentation of the duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and previously purchased DME items related to the billed items. There is insufficient documentation of the member's medical condition to substantiate the necessity for the type and quantity of items ordered. Therefore, we decided that the Plan does not have to pay for ankle braces (L1971) provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for DME and related supplies. We decided that the Plan does not have to reduce the cost-sharing charges for DME and related supplies. You asked the Plan to reduce the cost-sharing charges for DME and related supplies. You say that you disagree with the charges.The Plan says that the claims were processed correctly and you are being charged the correct amount.We decided that the Plan has to reduce the cost-sharing charges for DME and related supplies from $83.50 to $82.16.The plan contract says that you must pay 20% coinsurance for DME and related supplies. The total allowed amount is $410.82 and 20% of that is $82.16. Therefore, we decided that the Plan has to reduce the cost-sharing charges forDME and related supplies from $83.50 to $82.16. We also decided that the Plan does not have to waive the cost-sharing charges for DME and related supplies to the amount you requested. 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 DME and related supplies.Therefore, we decided that the Plan does not have to waive the cost-sharing charges for DME and related supplies.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on February 11, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you were told by an insurance representative that there would be no copayment for this procedure. You say it was your understanding that this was a cancer screening. 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 $175 copayment for each Medicare-covered advanced radiology service.  
 
You have been asked to pay a $175 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the CT scan of the neck is considered an advanced radiology test. 
 
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 CT scan provided on February 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve5 additional physical therapy visits.You asked the Plan to pre-approve5 additional physical therapy visits. You say that therapy is necessary in order to maximize the enrollee's potential functional gains.The Plan denied your request. The Plan says the enrollee no longer needs therapy.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 5 additional physical therapy 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 the requested therapy is generally not accepted as specific and effective therapy for the patient's condition. The patient has reached a functional level that in addition the five more authorized physical therapy sessions will no longer requires the skills of a professional therapist. She should be able to transition to an independent home exercise program and does not need the remaining five visits with the unique skills of a professional therapist to safely and effectively provide 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 5 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve5 additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance rides provided on August 8, 2019 to August 13, 2019.
You asked the Plan to waive the copayment for the ambulance rides. You say that you have met your maximum out-of-pocket amount. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for each Medicare-covered one-way trip. The enrollee has been asked to pay a $150 copayment for each of the ambulance rides. The ambulance rides fall within the "Ambulance services" benefit category. The record shows that the maximum out-of-pocket amount had not been met at the time the services were rendered.
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. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance rides provided on August 8, 2019 to August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 20, 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 February 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2020. You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 20, 2019.
You asked the Plan to pay for the physician's services. You say that you were not aware that the authorization
obtained did not include this date of service. The Plan denied your request. The Plan says the enrollee must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from 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 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 physician's services provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 31, 2019.
You asked the Plan to pay for the laboratory services. 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 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 December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for home health services. You say that it is the facility's responsibility to obtain prior authorization. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 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 home health services provided on February 13, 2020 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 provided on October 24, 2019.
You asked the Plan to pay for the laboratory 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided on November 20, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis and suspension sleeve. You say that you would like reconsideration because this equipment is medically necessary.The Plan denied your request. The Plan says the record does not include any evidence of an established relationship between the member and the ordering physician.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The information submitted does not confirm that Medicare coverage criteria have been met.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) and suspension sleeve (L2397) provided on November 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care provided on January 9, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for initial hospital care. You say that you would like this appeal reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 initial hospital care provided on January 9, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5011, V5261, V5160, V5014) provided October 18, 2019 to December 4, 2019. You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered. The Plan denied your request. The Plan says at the time the hearing aids were purchased, you had no supplemental benefits for hearing aids and they are not covered by Medicare. The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids (V5011, V5261, V5160, V5014) provided October 18, 2019 to December 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 7, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you had chest pain and couldn't breathe. You say that you are appealing the $200 charge. 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 $200 per one-way trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 ambulance transport provided on December 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the core build up (D2950) and crown (D2740) provided on February 6, 2020.
You asked the Plan to pay the full amount for the dental services. You say that your dentists advised they had received verification of coverage for the services that you received prior to the date of service. The Plan denied your request. The Plan says the dental services that you received are listed as covered services. The Plan says there is an annual maximum benefit of $1,000 for dental services. The Plan says the annual maximum benefit was exhausted during the processing of your claim. The Plan also says any amount above the annual maximum is your responsibility.
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 and the core build up and crown are covered services, the annual maximum benefit of $1,000 has been exhausted.
The Evidence of Coverage clearly states that any amount over the annual maximum is your responsibility. Therefore, we decided that the Plan does not have to pay the full amount for the core build up (D2950) and crown (D2740) provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the bone marrow biopsy and the CT scan provided on January 9, 2020 and February 4, 2020.You asked the Plan to waive the copayments for the bone marrow biopsy and the CT scan. You say that you should not be responsible for the copayment because the tests were unnecessary. 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 $350 copayment per date of service at an outpatient hospital facility and a $150 copayment per provider, per date of service for complex radiology (MRI/MRA, CT scans, nuclear cardiology studies). You have been asked to pay a $350 copayment for the bone marrow biopsy and a $150 copayment for the CT scan. The bone marrow biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the bone marrow biopsy and the CT scan provided on January 9, 2020 and February 4, 2020. Your complaint about the incorrect diagnosis is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat
exchanger provided on January 23, 2020.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to
the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this
claim cannot be paid separately based on Medicare guidelines for inpatient services. The Plan says that this
claim should be submitted to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers.
This equipment was used during and after a surgical procedure by the facility. Payment for this service would
have been included under the facility claim. Payment to you for this service is the responsibility of the facility
or hospital. Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with
oxygenator or heat exchanger provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transcutaneous electrical nerve stimulation (TENS) device.You asked the Plan to pre-approvea TENS device. You say that to avoid surgery you need a TENS device for your chronic back pain.The Plan denied your request. The Plan says your records do not state that you are in a clinical study.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a TENS device have not been met.Therefore, we decided that the Plan does not have to pre-approvea transcutaneous electrical nerve stimulation (TENS) device.