Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided at the Hospital from September 23, 2019 to September 27, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. 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 $150 copayment per day for days 1-10 for inpatient hospital care. You had an inpatient hospital stay from September 23, 2019 to September 27, 2019. Therefore, you are responsible to pay $450, which is less than the total copayment amount. You have been asked to pay $450 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 for an inpatient hospital stay provided at the Hospital from September 23, 2019 to September 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter removal provided on October 10, 2019.
You asked the Plan to waive the copayment for the catheter removal. You say that the catheter wasn't needed. You say that having the catheter delayed other treatments. 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 a $325 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $325 copayment for the catheter removal. The catheter removal 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 for the catheter removal provided on October 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on July 5, 2019.
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that self-administered drugs in an outpatient setting are 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 pay for the self-administered drugs provided on July 5, 2019.
Benefits for these drugs 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on November 14, 2019.You asked the Plan to waive the copayment foran X-ray. You say that you were not charged in the past and 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 $10 copayment for each basic imaging service. You have been asked to pay a $10 copayment for an X-ray. An X-ray 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 X-ray provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision lenses purchased from an out-of-network provider on October 16, 2019.
You asked the Plan to pay for the vision lenses. You say that you paid $318.67 for V2784, polycarbonate lenses and according to your plan you are entitled to a reimbursement of $70. The Plan denied your request. The Plan says enrollee's must receive their vision services from a participating optical provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered by a participating provider. We looked at the file and the Plan's rules. Vision services provided by a non-participating provider is not covered by the plan. Based on this information, we decided that the Plan's rules for coverage of the vision lenses have not been met. Therefore, we decided that the Plan does not have to pay for the vision lenses purchased from an out-of-network provider on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.
You asked the Plan to pre-approve the maxillary partial denture. You say that dentures and partials are benefits under your plan. The Plan denied your request. The Plan says Medicare does not cover this service.
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 a maxillary partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain crown (D2740) for tooth # 9.
You asked the Plan to pre-approve the dental service. You say that you received a crown for tooth # 9 in 2017. You say that your crown broke and the dentist you saw in 2017 will not fix it. You say that the dentist did not put the crown in correctly which let to it breaking less than 3 years later. The Plan denied your request. The Plan says crowns are covered once per tooth every 5 years. The Plan also says that the frequency limit 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, the frequency limit for a crown for tooth # 9 has been reached. The record shows you last received a crown for tooth # 9 on August 28, 2017. Therefore, we decided that the Plan does not have to pre-approve the porcelain crown (D2740) for tooth # 9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October 16, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that the visit was for an annual glaucoma screening and you should not have a copayment. 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 $45 copayment for each in-network Medicare-covered visit. You have been asked to pay a $45 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows you have already been diagnosed with primary open angle glaucoma, severe stage.
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 medical eye exam provided by the physician on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased September 12, 2019.
You asked the Plan to pay for the hearing aids. You say that the provider took your insurance cards and you were never told that they were not a participating provider and you also was not notified that the services was denied. The Plan denied your request. The Plan says this service is not covered under the benefits package.
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. The Plan says that fitting and evaluations for hearing aids and hearing aids are not covered. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids purchased September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe electric recliner (E1399).You asked the Plan to pre-approvethe electric recliner. You say that you need assistance to get up from any type of chair and getting up from a chair is very painful to your back and right shoulder and your doctor is recommending you to get an electric chair.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that electric recliners are not covered because they are not primarily medical in nature. While a recliner may be appropriate in this case, neither the Plan nor Medicare offers coverageof this item.Therefore, we decided that the Plan does not have to pre-approvethe electric recliner (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that you need this item due to a medical condition resulting from radiation treatments for prostate cancer.The Plan denied your request. The Plan says these items are not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and two full leg garments (E0667).
You asked the Plan to pre-approve a pneumatic compression device and two full leg garments. You say that you are requesting an appeal regarding the denial of coverage for the Flexitouch pneumatic compression pump. The Plan denied your request. The Plan says there is no documentation that you have tried and failed 4 weeks of treatment with E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and two full leg garments (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home Safety Tub purchased on January 3, 2019.
You asked the Plan to reimburse you for the home Safety Tub. You say that cleansing skin is medically necessary and essential. The Plan denied your request. The Plan says bathtubs are not primarily and customarily used to serve a medical purpose.
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. Medicare does not cover home modifications. Therefore, we decided that the Plan does not have to reimburse you for the home Safety Tub purchased on January 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam (S0621) and special contact lens fitting (92310) provided April 23, 2019.
You asked the Plan to pay for the vision services. You say that you were a few weeks early on the eye exam and you request reconsideration The Plan denied your request. The Plan says this request exceeds the benefit limit of 1 routine eye exam every 12 months.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when one routine eye exam every 12 months. The records show that you received a routine eye exam on July 5, 2018. This benefit would not be eligible until July 2019.
We looked at the file and the Plan's rules. the enrollee is only allowed one routine eye exam every 12 months. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam (S0621) and special contact lens fitting (92310) provided April 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services
You asked the Plan to pre-approve the physician's services. You say that you need to have hand surgery and you want the surgery to be performed by this physician because he has experience performing fasciectomy surgery. The Plan denied your request. The Plan says the service requested is available and accessible with an in-plan provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for services provided on May 16, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says that they denied for PPG/Hospital Risk.
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. The Plan did not provide information to support their denial. Therefore, we decided that the Plan has to pay for services provided on May 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you cannot carry your portable tanks and this is forcing you to stay at home. The Plan denied your request. The Plan says Medicare covers oxygen equipment that is appropriate and needed for use in the home.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The record shows that you have a home oxygen system with refillable portable tanks. This stationary oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 18, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that the service was provided in a doctor's examination room. You say you should not be responsible for the copayment. 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 $45 copayment for each in-network covered specialist office visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls 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 copayment for the specialist office visit provided on June 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for2 knee orthosis (L1833) provided March 1, 2019.You asked the Plan to pay forthe orthoses. You say that you are requesting an appeal on the denial of the claim.The Plan denied your request. The Plan says the records do not support the necessity of the services in dispute.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 orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no contemporaneous medical records submitted for review on or around the date of prescription, 3/1/19. There is no evidence that the enrollee had a recent injury or surgery to the knee. There is no documentation of a subjective complaint of instability or knee instability on physical exam. There is no discussion in the medical records relative to any knee complaint or abnormal knee exam, or history of recent trauma. Knee surgery is not reported. Therefore, the enrollee does not meet Medicare coverage criteria for the two requested knee orthoses.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 orthoses have not been met.Therefore, we decided that thePlan does not have to pay for2 knee orthosis (L1833) provided March 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you would like these office visits approved. The Plan denied your request. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveroutine wheelchair transportation.You asked the Plan to pre-approvewheelchair transportation. You say that you have an upcoming appointment and you need transportation.The Plandenied your request. The Plan says the records do not support medically necessary criteria for coverage.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 routine transportationwhen Wheelchair van transportation, may be covered in lieu of ambulance transportation when the Plan determines such transport is reasonable and medically necessary to safely transport (to medical appointments) a wheel chair dependent member who: is unable to ambulate with or without assistance, and with or without an assistive device; is unable to safely transfer from a wheelchair to a private vehicle, with or without assistance; requires medical transportation whenever he/she accesses the community for any purpose and cannot be safely transported by private car or taxi.. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveroutine wheelchair transportation.