Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided on February 24, 2021.

You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare Part B drug. You say that you were being treated for long hauler syndrome due to COVID-19 and thought that all cost-sharing was waived. 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 $5 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 

You had a specialist visit on February 24, 2021. The record shows that this visit does not qualify for the COVID-19 copayment waiver. Therefore, you are responsible to pay the $5 copayment. 

You received a Medicare Part B drug on February 24, 2021. Medicare Part B drugs are not included in the COVID-19 waiver. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $702.24 and 20% of that is $140.45.

The total amount you owe is: $145.45.

You have been asked to pay the total copayment amount of $145.45 for a specialist visit and a Medicare Part B drug. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive the coinsurance for a Medicare Part B drug provided on February 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on July 10, 2020.

You asked the Plan to pay for the therapeutic activities. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat elevator (E2300), seat belt (E0978) and gel pads (K0108).

You asked the Plan to pre-approve the seat elevator, seat belt and gel pads. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says the elevator and seat belt do not service a medical purpose and the seat belt is included in the approved wheelchair.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say that codes listed in Column II are not separately payable from the wheelchair base and must not be billed separately. 

The requested seat elevator and gel pads do not serve a purpose that is primarily medical in nature. Additionally, the requested seat belt is included in the wheelchair base. Therefore, we decided that the Plan does not have to pre-approve the seat elevator (E2300), seat belt (E0978) and gel pads (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203), an avulsion of nail plate (11730), debridement of extensive eczematous or infected skin (11000) and debridement of nail(s) (11721) provided on February 12, 2021, by an OON provider.
You asked the Plan to pay for an office visit and podiatry services. You say that you are requesting reconsideration of payment on this claim. The Plan denied your request. The Plan says services were provided 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99203), an avulsion of nail plate (11730), debridement of extensive eczematous or infected skin (11000) and debridement of nail(s) (11721) provided on February 12, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on October 17, 2020.

You asked the Plan to waive the copayment for urgently needed services. You say that this was an urgent care visit and you should not owe a copayment. 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 $30 copayment for urgently needed services. 

You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 for urgently needed services provided on October 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from February 27 to March 1, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you think the copayment is too high and you are on a fixed income. The Plan denied your request. The Plan says the correct copayment was 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 $290 copayment for each day of days 1 to 5 of each Medicare-covered hospital stay.

You have been asked to pay a $580 copayment for a two-night stay for inpatient hospital care. 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 inpatient hospital care provided from February 27 to March 1, 2021.
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. You say that the services 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 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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered when treatment has completed and the enrollee's oral intake is more stable.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes with inserts.

You asked the Plan to pre-approve diabetic shoes with inserts. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if specific criteria are met. 

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 diabetic shoes with inserts. Our reviewer says that the items are not medically necessary. Our physician reviewer found you have diabetes mellitus but the documentation does not indicate that you have a previous amputation of the other foot, or part of either foot, or previous foot ulceration of either foot, or history of pre-ulcerative calluses of either foot, or peripheral neuropathy with evidence of callus formation of either foot, or foot deformity of either foot, or poor circulation in either foot. The coverage criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diabetic shoes with inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes with inserts.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crowns (D6750 x2), and pontic (D6240) provided on
December 10, 2020.
You asked the Plan to pay for retainer crowns, and pontic. You say that you were not aware that the maximum
benefit allowed had been reached. You are on a limited income and would not have proceeded if you were
aware. The Plan denied your request. The Plan says the services at issue are covered benefits, however the
benefit maximum had already been met.
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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of retainer crowns, and pontic have not been met. Specifically, the record shows that you had
exhausted your dental benefit maximum. Therefore, we decided that the Plan does not have to pay for retainer
crowns (D6750 x2), and pontic (D6240) provided on December 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of an interspinous spacer device (22869, 22870).
You asked the Plan to pre-approve the insertion of an interspinous spacer device. You say that this is medically necessary and covered by Medicare. The Plan denied your request. The Plan says this is experimental.
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 insertion of an interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous process devices remain experimental in spine surgery. More research is needed to show safety and efficacy of the devices.
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 insertion of an interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of an interspinous spacer device (22869, 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa syringe.

You asked the Plan to pre-approve Euflexxa syringe; Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323). You say that you would like the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and failed Orthovisc and Monovisc.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Euflexxa syringe; Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the patient has tried and failed Monovisc but has not tried and failed Orthovisc. Based on the medical records provided there is no indication that Orthovisc would likely be less effective and/or likely have adverse effects for the patient.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa syringe; Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose (J7323) have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa syringe.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided on November 19, 2020, and December 8, 2020.
You asked the Plan to waive the copayments for office visits. You say that you feel that the services do not justify a copayment because you were only seen for a foot measurement and to pick-up your shoes. 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 $20 copayment for physician/practitioner services, including doctor's office visits.
The record shows that you had on office visit on November 19, 2020. Therefore, you are responsible to pay the
$20 copayment.
The record shows that you had on office visit on December 8, 2020. Therefore, you are responsible to pay the
$20 copayment.
The total amount you owe is: $80.
You have been asked to pay the total copayment amount of $80 for office visits. Office visits fall within the
physician/practitioner services, including doctor's office visits 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 office visits provided on November 19, 2020, and December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 14, 2020.

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 had network providers available who could have provided 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 services provided by an out-of-network provider on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a treadmill (E1399).
You asked the Plan to pre-approve a treadmill. You say that you have equilibrium issues and it is hard for you to walk without falling. Your doctor recommended a treadmill or a standing bike. You've had a standing bike before which helped a lot. The Plan denied your request. The Plan says this item is exercise equipment and is not covered.
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 a treadmill (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two guided tissue regenerations (D4266 x2), two surgical placements of implant bodies: endosteal implants (D6010 x2), and two bone grafts at time of implant placement (D6104 x2).
You asked the Plan to pre-approve the guided tissue regenerations, endosteal implants, and bone grafts. You say that you could not find any in-network providers to render the services, unless you were to wait a number of years due to COVID. You also say that the provider you saw you have seen for 26 years. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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 two
guided tissue regenerations (D4266 x2), two surgical placements of implant bodies: endosteal implants (D6010 x2), and two bone grafts at time of implant placement (D6104 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits on January 4, 2021 and January 6, 2021.
You asked the Plan to pay for the office visits. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the physician opted out of Medicare on October 21, 2011.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visits on January 4, 2021 and January 6, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on November 30, 2020. You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on November 30, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 11, 2020.
You asked the Plan to pay for the ambulance services. You say that this claim is for the treatment at the scene. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 11, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 11, 2020