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

We decided that the Plan does not have to waive the copayment forthe medical eye exam provided on October 7, 2019.You asked the Plan to waive the copayment forthe medical eye exam. You say that you were told you would have to come back at a later date to do the eye exam. You say you were told you would 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 $40 copayment for each Medicare-covered outpatient visit for services to diagnose and/or a disease or condition of the eye. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows you were seen for blurred vision and a right zygomatic arch and lateral orbital wall fracture which makes the visit medical in nature.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 medical eye exam provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone replacement graft (D7953).
You asked the Plan to pre-approve the bone replacement graft (D7953). You say that you have pain in your teeth, gums and jaw bone. You say you are missing four of your front teeth and unable to eat. The Plan denied your request. The Plan says the bone replacement graft (D7953) is not a covered benefit.
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 bone replacement graft (D7953) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the bone replacement graft (D7953.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker with an enclosed frame.You asked the Plan to pre-approve a walker with an enclosed frame. You say that you need a walker to assist with your walking.The Plan denied your request. The Plan says that a new walker is allowed once every 5 years.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. You received a walker on July 17, 2018, which is less than five years ago.Therefore, we decided that the Plan does not have to pre-approve a walker with an enclosed frame
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from October 16, 2018 to March 19, 2019.
You asked the Plan to pay for these services. You say that this was billed correctly and should be reconsidered for payment. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. The rules say 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. You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from October 16, 2018 to March 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Power Mobility Device. You asked the Plan to pre-approve a Power Mobility Device. You say that you need a Power Mobility Device for increased ease with community distances. The Plan denied your request. The Plan says your evaluation shows you use a cane and are able to do your ADLs on your own or with the equipment you have. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, and your condition can be improved by your cane. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Power Mobility Device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided at an outpatient hospital facility on January 13,2020.You asked the Plan to waive the copayment for wound debridement. You say that you disagree with the additional $50 charge.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correctamount.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 $50 copayment for each specialist visit. You have been asked to pay a $50 copayment for wound debridement. Wound debridement 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 for wound debridement provided at an outpatient hospital facility on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foreye examination. You say that these services were ordered by the nursing facility as medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because thisprovider is out-of-network with the Plan and prior authorization was not 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 topay 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 September 23, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health servicesrendered from April 1, 2019 to April 19, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment.We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid TOB code.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 forthe home health services rendered from April 1, 2019 to April 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese 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.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 December 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient hospital visit provided on November 26, 2019.You asked the Plan to waive the copayment foran outpatient hospital visit. You say that you should only owe a $50 specialist copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correctamount.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 $300 copayment for outpatient hospital visits. You have been asked to pay the allowed amount of $124.34, which is less than the $300 copayment for an outpatient hospital visit. An outpatient hospital visit falls within the outpatient hospital services benefit category. This meansthat 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 outpatient hospital visit provided on November 26, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forthe ambulance services provided to the enrollee on July 23, 2019.You asked the Plan to pay forthe ambulance services. You say that  The Plan denied your request. The Plan says that that the automobile insurance carrier's payment and the Plan's paymentshould not exceed their normal allowable amount.The Plan must follow Medicare rules. The rules state that that Medicare secondary payment amounts are determined by a formula and are the lowest of:1) Excess of the actual charge minus the primary payment;2) The amount Medicare would pay if the services were not covered by a primary payer;3) The higher of the Medicare payment amount or the primary payers allowable charge minus the amount actually paid by the primary payer.The breakdown of Medicare secondary payment is as follows:1) $683.50 (actual charge) minus $546.80 (amount paid by primary) equals $136.702) Amount Medicare would pay $546.80 times 0.8 equals $437.44 (this is the amount Original Medicare would pay, the allowed times 80% coinsurance)3) $683.50 (the higher between the Medicare amount and the primary payers allowable) minus $546.80 (the amount the primary payer paid) equals $136.70.Medicare will pay the lowest of these amounts. The lowest amount is $136.70.Therefore, we decided that the Plan has to pay forthe ambulance services provided to the enrollee on July 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services (99308) provided on October 24, 2019.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says services were not preauthorized or emergent. There were network providers available.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 physician services (99308) provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAccu-Chek test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that you have a hard time getting strips out of the tube without spilling them all over the place.The Plan denied your request. The Plan says there is no medical reason documented that you are medically unable to use the Plan preferred test strips.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test stripshave not been met.Therefore, we decided that the Plan does not have to pre-approveAccu-Chek test strips
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism of a seat lift chair.
You asked the Plan to pre-approve a seat lift mechanism. You say that your knees are bad and you have a hard time getting up because of the pain. The Plan denied your request. The Plan says you are able to stand from standard height surfaces.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. Medicare does not cover the upholstered portion of a seat lift chair. We looked at the file and Medicare rules. The evaluation shows you are able to stand from standard height surfaces and do not meet medical necessity for a lift chair. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism of a seat lift chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 30, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab work provided on October 30, 2019 by an out
of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea storage basket attachment.You asked the Plan to pre-approvea storage basket attachment. You say that the enrollee needs a storage basket to carry equipment and avoid tipping the wheelchair over. The Plan denied your request. The Plan says a storage basket is for comfort, convenience and portability and therefore excluded from coverage.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 thegeneral 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-approvea storage basket attachment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decied that the Plan does not have to pay forthe medical services provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese 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 providedd on October 30, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on December 10, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you did not have any polyps removed. You say that you shouldn't have to pay the copayment for a routine screening. 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 surgery at an outpatient hospital facility. You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed, which is considered a diagnostic surgical procedure. 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 colonoscopy provided on December 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from September 10, 2019 to October 5, 2019.
You asked the Plan to waive the copayment for the SNF services. You say that you cannot afford to pay this. The Plan denied your request. The Plan says that you are responsible for the copayment.
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 copay and a $100 copayment for each day for days 1 through 20 of SNF care and each day for days 21 through 44 of SNF care. You have been asked to pay a $900 copayment for the SNF services. The SNF services falls within the days 1 through 20 of SNF care and days 21 through 44 of SNF 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 the skilled nursing facility (SNF) services provided from September 10, 2019 to October 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from August 1, 2019 to August 22, 2019.You asked the Plan topay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the claim was billed with an invalid type of bill for a non-participating Home Health provider.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was submitted with an invalid type of bill code..Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from August 1, 2019 to August 22, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe radiation treatment management services provided from November 19, 2019 to December 4, 2019.You asked the Plan to waive the copayments forthe radiation treatment management services. You say that you believe they are the same as copayment for an office visit and specialist visit. You say no procedure was done, just talked to you and asked how you were doing.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 with a specialist. You have been asked to pay a total of $565.65 for the radiation treatment management services. The radiation treatment management services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows your radiation treatment started on November 19, 2019 and was completed on December 11, 2019. See chart below. Date of ServiceServiceCopaymentCopayment for 5 treatmentsAllowed AmountMember LiabilityNovember 19, 2019Radiation management, 5 treatments$45$255$188.55$188.55November 25, 2019Radiation management, 5 treatments$45$255$188.55$188.55December 4, 2019Radiation management, 5 treatments$45$255$188.55$188.55Total$565.65This 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 forthe radiation treatment management services provided from November 19, 2019 to December 4, 2019.