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

We decided that the Plan does not have to waive the copayment for the CPAP device (E0601) provided from
November 18, 2019 through December 18, 2019.
You asked the Plan to waive the copayment for the CPAP device. You say that you are appealing your costshare
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received the CPAP device (E0601) provided from November 18, 2019
through December 18, 2019. You have a $15 copayment for DME, each month this applies for your durable
monthly copay for your CPAP machine. You received the equipment and started getting monthly rental copays
of $15 starting in November 2019. You are responsible for the total copayment assessed of $30, $15 for
November and $15 from December. 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 CPAP device
(E0601) provided from November 18, 2019 through December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
December 10, 2019 to December 13, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that it was not you who was
admitted to the hospital. You say you would have never gone to this hospital. 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 $275
copayment per day for days 1 to 5 each time you are admitted to an acute care hospital.
You have been asked to pay a $275 copayment for the inpatient hospital stay. ($275 x 3 inpatient days = $875).
The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows the
inpatient stay was for the member in question because the member's date of birth and address match the
medical records.
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 inpatient hospital stay provided from December 10,
2019 to December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B injections and the ultrasound provided on April 10, 2019.
You asked the Plan to waive the cost share for the Part B injections and the ultrasound. You say that you do not have any coinsurance. 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 Medicare Part B covered drugs at an in-network specialist's office and a $40 copayment for basic radiological services at an in-network specialist's office. You have been asked to pay $2,538.65 which is 20% of the allowed amount for the Part B injections. The allowed amount is $12,693.25. ($12,693.25 x 20% = $2,538.65). You have also been asked to pay a $23.04 which is less than the standard copayment for the ultrasound. ($2,538.65 + $23.04 = $2,561.69). The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. The 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 cost share for the Part B injections and the ultrasound provided on April 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from January 8, 2020 to March
4, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the services
were obtained out-of-network and 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 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 physician's services provided from January 8, 2020 to March 4,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on
August 19, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the enrollee has previously received the same item from a different provider that is still
within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical
equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same orthosis from a different provider on September 21, 2018. This orthosis is still
within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn,
irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral
orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have
not been met. Furthermore, the documentation submitted did not include Proof of Delivery or an itemized
Delivery Ticket. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650)
provided to the enrollee on August 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a suction assisted lipectomy provided on January 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that you would like this information reviewed and reprocessed and payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 a suction assisted lipectomy provided on January 22, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder orthosis (L3670) and lumbar-sacral orthosis (L0650) provided to the enrollee on December 9, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 orthoses have not been met. Review of the file shows that the documentation submitted did not include a Proof of Delivery, or a Delivery Ticket. Therefore, we decided that the Plan does not have to pay for shoulder orthosis (L3670) and lumbar-sacral orthosis (L0650) provided to the enrollee on December 9, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for therapeutic injections. We decided that the Plan does not have to reduce the cost-sharing charges for therapeutic injections to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for therapeutic injections. You say that you have not been charged in the past and 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 therapeutic injections from the total amount of $30 to the total amount of $1.54.
The plan contract says that enrollee's must pay 20% coinsurance for Medicare Part B drugs. Therefore, you cannot be charged more than the total 20% coinsurance amount of $1.54. Therefore, we decided that the Plan has to reduce the cost-sharing charges for therapeutic injections from the total amount of $30 to the total amount of $1.54.
We also decided that the Plan does not have to reduce the cost-sharing charges for therapeutic injections 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 therapeutic injections. The allowed amount per each injection is $3.87 and 20% of that is $.77. The total amount you owe is: $.77 (coinsurance amount) x 2 (injections) = $1.54. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for therapeutic injections.
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 pay for the wrist/hand orthosis provided to the enrollee on February 4, 2020.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that documentation submitted did not indicate the provider discussed the need for the billed supply code.
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 pay for the orthosis. Our reviewer says that the requested orthosis is not considered medically reasonable and necessary in this case. There is no documentation to support that the wrist/hand orthosis at issue in this case is medically reasonable and necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the orthosis. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the wrist/hand orthosis provided to the enrollee on February 4, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the acupuncture treatment provided on January 30,
2020. We also decided that the Plan does not have to pay for the acupuncture treatment provided on
January 15, 2020.
You asked the Plan to pay for the acupuncture treatment. You say that acupuncture seems to be helping as you
are able to walk with very little pain. The Plan says that acupuncture is not a covered benefit under your
contractual policy.
We decided that the Plan has to hold you harmless for the acupuncture treatment provided on January 30,
2020. As of January 21, 2020, acupuncture is a covered benefit of Medicare. The record indicates that the
provider in this case is contracted with the Plan. Contracted providers are considered agents of the Plan.
The record does not show that you were given notice that the acupuncture services would not be covered. The
EOC does not serve as adequate notice of non-coverage in this case, as acupuncture is a Medicare-covered
benefit effective January 21, 2020. Therefore, we decided that the Plan has to hold you harmless for the
acupuncture treatment provided on January 30, 2020.
We also decided that the Plan does not have to pay for the acupuncture treatment provided on January 15,
2020 as acupuncture was not a covered benefit of Medicare at this time. Therefore, we decided that the Plan
does not have to pay for the acupuncture treatment provided on January 15, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 13, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the place of service
on the claim must reflect the location where the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that the POS code reflects the actual place where the
beneficiary receives the face-to-face service.
We looked at the file and the rules. The documentation provided does not show that the specimen sample was
taken in the independent laboratory. Based on this information, we decided that Medicare rules for coverage of
have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on
January 13, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve a continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the enrollee is suffering from kidney problems
due to having Covid-19. The Plan denied your request. The Plan says that the enrollee is clinically stable and is
able to transfer with the stand-by assistance of another person. The Plan says that the care required is custodial
in nature.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan did not provide medical records or evidence of having
made reasonable attempts to obtain this necessary documentation. Therefore, we decided that the Plan has to
pre-approve a continuation of skilled nursing facility (SNF) care.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Toujeo Solostar 300 unit/ml.
You asked the Plan to pre-approve Toujeo Solostar 300 unit/ml. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Toujeo Solostar 300 unit/ml.
Benefits for Toujeo Solostar 300 unit/ml 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10mg Predisone tablets (J7512).
You asked the Plan to pre-approve the Prednisode. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered by the member's Medicare Part B benefits.
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 10mg Predisone tablets (J7512).
Benefits for the Prednisode 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 pre-approve a sleep study.
You asked the Plan to pre-approve the sleep study. You say that you would like reconsideration because the member has difficulty sleeping. The Plan denied your request. The Plan says the member does not meet coverage criteria for the sleep study.
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 sleep study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not meet the Medicare LCD criteria for the sleep study. 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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on August 27, 2019 from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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. The provider is not in-network and your EOC clearly states, routine hearing services must be received from a participating provider in order to be covered by the plan. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on August 27, 2019 from an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on January 10, 2020.You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 surgical pathology services provided on January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the quadriceps tendon repair surgery provided on December 2, 2019.
You asked the Plan to waive the coinsurance for the tendon repair surgery. You say that you do not have the money to pay this bill. You say this was outpatient surgery with no hospital stay required. 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 Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $1,609.33 which is 20% of the allowed amount for the tendon repair surgery. The allowed amount is $5,346.67. ($5,346.67 x 20% = $1,609.33). The tendon repair surgery falls within the "Outpatient Surgery and Other Medical 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 coinsurance for the quadriceps tendon repair surgery provided on December 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from September 12, 2019 to November 21, 2019. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 
 
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from September 12, 2019 to November 21, 2019.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.