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

We decided that the Plan does not have to pay for the drug testing services provided on August 14, 2019 by out of network (OON)) provider.

You asked the Plan to pay for the OON lab services. You say that this claim should be paid as the provider was not aware of prior authorization requirements and this testing was performed in good faith based on the physician's order. The Plan denied your request. The Plan says this testing was ordered by an OON provider outside of an emergency situation and no authorization was obtained for the physician services or for the OON lab testing. As such, this is correctly denied.

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 drug testing services provided on August 14, 2019 by out of network (OON)) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator, backpack accessory and
sales tax provided on August 3, 2019.
You asked the Plan to pay for these services. You say that the portable oxygen machine helps you from feeling
tired out. The Plan denied your request. The Plan says that purchased oxygen equipment is excluded from
coverage.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is excluded from
coverage.
We looked at 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 pay for the
portable oxygen concentrator, backpack accessory and sales tax provided on August 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on July 22, 2019.You asked the Plan to pay forthe services. You say that the services were medically necessary.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 forthe medical services provided to by an out-of-network provider on July 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq.
You asked the Plan to pre-approve Myrbetriq. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq.
Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on September 3, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that this was part of a breast cancer screening and 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 $35 copayment for X-rays.You had an ultrasound on September 3, 2019.An ultrasound is not included in a breast cancer screening. Therefore, you are responsible to pay the $35 copayment.  You have been asked to pay a $35 copayment for an ultrasound. An ultrasound 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 copayment foran ultrasound provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on August 16, 2019.
You asked the Plan to pay for office visit. You say that you were taken to this provider by the nursing home and did not know the provider was out-of-network. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the code billed by this out-of-network provider is not valid for Medicare use.
The Plan must follow Medicare rules. Medicare rules say that procedure code 99245 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. The out-of-network provider billed for this service using a code that is not valid for Medicare purposes, therefore this service cannot be paid as it has been billed on this claim. Based on this information, we decided that Medicare rules for coverage of office visit have been met. Therefore, we decided that the Plan does not have to pay for an office visit provided on August 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 10, 2019 by out of network provider, "the medical center". You asked the Plan to pay foroutpatient surgery. You say that there was a problem with finding the member in the system. You say that the office did everything they could do verify the member's enrollment.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 Plandoes not have to pay forthe medical services provided on April 10, 2019 by out of network provider, "the medical center". We note your complaint about being told by the Plan that the member was in the network.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 pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH
admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is no documentation provided that necessitates transfer to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 18, 2019 by out of network provider.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 were rendered by an out-of-network provider 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 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 forthe medical services provided on April 18, 2019 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation (A0120).You asked the Plan to pre-approveadditional routine transportation. You say that you have multiple appointments per month andyou are unable to drive yourself.The Plan denied your request. The Plan says the requested services exceed the benefit allowance. Therefore, coverage criteria has not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of additional routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe facility fee provided on July 24, 2019.You asked the Plan to waive the copayment forthe facility fee. You say that the facility charge is ridiculous. You say you should not have to pay this charge because it was a return visit when you saw your doctor. 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 $200 copayment for in-network outpatient services including surgery, observation, and clinic. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $200 copayment for the facility fee.You have been asked to pay a $97.39 copayment for the facility fee. The facility fee falls within the "Outpatient hospital services" 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 forthe facility fee provided on July 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent for the enrollee.
You asked the Plan to pre-approve Praluent. You say that this is medically necessary. The Plan denied your request. The Plan says that this isn't covered by Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent for the enrollee.
Benefits for Praluent may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe replacement of gastrostomy tube on August 13, 2019.You asked the Plan to waive the copayment forthe replacement of gastrostomy tube. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the replacement of gastrostomy tube on August 13, 2019. The replacement of gastrostomy tube is an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $221.27, which is less than the $325 copayment. You have been asked to pay $221.27 for the replacement of gastrostomy tube. The replacement of gastrostomy tube falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 forthe replacement of gastrostomy tube provided on August 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 4, 2018 .You asked the Plan to pay forthe medical services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe medical services provided on June 4, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ophthalmoscopy provided on June 18, 2019.You asked the Plan to waive the copayment forthe ophthalmoscopy. You say that you should have been charged yourcopayment at the time of the visit. You say that you do not feel responsible for the copayment.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 $20 per day for Medicare-covered tests. You have been asked to pay a $20 copayment for the ophthalmoscopy. The ophthalmoscopy. falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 forthe ophthalmoscopy provided on June 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures.You asked the Plan to pre-approve the dental item. You say that the dentures you received from another provider do not fit after repeated attempts. You say that they lost your impression and continue to have you see new staff and dentists at each visit. You also say that now you want the new provider to be paid to make a new pair instead. The Plan denied your request. The Plan says the frequency limit of once every 5 years has been reached.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 dentures are listed as a covered service, the frequency limit has been reached. The record shows that you last received a pair of dentures on January 8, 2019.Therefore, we decided that the Plan does not have to pre-approve dentures.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvewide running or walking shoesYou asked the Plan to pre-approvefoot orthotics. You say that you were diagnosed with flat foot and have bad feet and cannot walk properly. Regular shoes do not fit properly and you cannot afford the costs of proper footwear.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvewide running or walking shoes
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the perflutren lipid microspheres injection provided on October 7, 2019.You asked the Plan to waive the coinsurance forthe perflutren lipid microspheres injection. You say that you have had this done in the past andwere not charged coinsurance.The Plan denied your request. The Plan says that the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Yourcontract with the Plan says that enrollees must pay 0% coinsurance for medical supplies.The Plan says you must pay $19.36 for the perflutren lipid microspheres injection. Based on the Plan contract, however, you cannot be asked to pay more than 0% coinsurance.The perflutren lipid microspheres areconsidered a medical supply. Therefore, we decided that the Plan has to waive the coinsurance forthe perflutren lipid microspheres injection provided on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 27, 2019 to August 28, 2019.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were discharged the next day and disagree with the charges.The Plan denied your request. ThePlan 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 $250 copayment per day for days 1-7 for inpatient hospital care. The medical records show that you had an inpatient hospital stay from August 27, 2019 to August 28, 2019. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment 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 August 27, 2019 to August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 12, 2019 by the out of network provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on March 12, 2019 by the out of network provider.