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

We decided that the Plan does not have to waive the coinsurance for prosthetic sock, single ply, fitting, below knee, each (L8470) provided to the enrollee on November 11, 2019.
You asked the Plan to waive the coinsurance for the prosthetic socks. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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). Per the member's Explanation of Benefits (EOB) it does show the member's responsibility is $39.60 which is the Medicare allowable. In addition; the allowable copayment on this claim line is $6.60 per unit and there are 6 units as shown here, which is less than the member's $10 copayment per item, so this shows in the member's favor. The plan researched the member's claim history and found that on February 13, 2019 with the provider, the member was assessed a copayment of $39.60 for code L8470, which was also the Medicare allowable. The provider billed for code L8470 to the plan in the amount of $45.78, the plan paid $0.00 with the Medicare allowable of $39.60. This was assessed to member responsibility as it is a lesser amount then the $10 for each Medicare-covered prosthetic device ($10 X 6 units = $60). There is no sequestration on this code. Per the above benefits the plan's decision is to uphold the original claim processing and the member's cost share of $39.60.
Per the member's plan benefits the Prosthetic Devices and Related Supplies applied correctly. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for prosthetic sock, single ply, fitting, below knee, each (L8470) provided to the enrollee on November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the coinsurance amounts applied to the pre-fabricated post and core in addition to a crown (D2954), the crown (D2740) and the root canal (D3310) for tooth # 6 provided on January 29, 2019.You asked the Plan to reimburse you for the coinsurance amounts applied to the dental services. You say that the dental services had been previously approved by the Plan. You say that you realized there are copayments and coinsurance that must be paid. You also say that the 50% coinsurance is unreasonable.The Plan denied your request. The Plan says the 50% coinsurance was applied correctly to the crowns and root canal that you received.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and the crowns and root canal are listed as covered services, there is a coinsurance amount that applies to these services. The Evidence of Coverage clearly states there is a 50% coinsurance for crowns and endodontic therapy. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.Therefore, we decided that the Plan does not have to reimburse you for the coinsurance amounts applied to the pre-fabricated post and core in addition to a crown (D2954), the crown (D2740) and the root canal (D3310) for tooth # 6 provided on January 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee.
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 documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on December 29, 2019 by an in network dentist.
You asked the Plan to pay for the dental service. You say that bitewing x-rays are a standard part of your dental care. The Plan denied your request. The Plan says only specific dental x-rays are covered. The Plan also says bitewing x-rays are not listed as a covered 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 bitewing x-ray is not among those covered under this benefit. The Evidence of Coverage clearly states that intraoral, complete series of x-rays, and panoramic x-rays are covered dental x-rays. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on December 29, 2019 by an in network dentist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from October 4, 2019 through October 15, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that the enrollee reached their out-of-pocket maximum of $10,000.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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). The enrollee has a $10,000, maximumout-of-pocket annual amount. The enrollee had met $1,085.36 of the out of pocket annual maximum prior to this claim being processed. The enrollee was admitted into the hospital on October 4, 2019 and was discharged on October 15, 2019.  The enrollee is responsible for $395 per day copay For days 1-4; $0 per day, days 5-90, therefore member is responsible for $1,580 ($395 X 4). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from October 4, 2019 through October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on February 5, 2020.You asked the Plan to waive the copayment for an eye exam. You say that you disagree with the charges because diabetic eye exams should be covered.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 $0 copayment for diabetic retinopathy screenings and a $30 copayment for exams to diagnose and treat disease and conditions of the eye.The medical records show that you received services beyond a diabetic eye exam on February 5, 2020. Therefore, you are responsible to pay the $30 copayment.  You have been asked to pay a $30 copayment for an eye exam. An eye exam falls within the vision 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 eye exam provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on June 12, 2019.
You asked the Plan to pay for the hearing aids. You say that you purchased 2 hearing aids for $1599.99. You did not realize at the time that hearing aids were available from the plan. The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider.
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 pays for hearing aids only when provided by an in-network provider. 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. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on June 12, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for medical records to be sent from one facility to another facility.
You asked the Plan to pay for medical records. You say that you feel that the plan should pay for this. The Plan denied your request. The Plan says these charges are not payable.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Providers are allowed to charge fees for access to protected health information. Medicare rules also say that only services that are reasonable to treat or diagnose an illness or injury are covered. While the provider is allowed to charge a fee for access to your records, this service does not directly treat or diagnose a medical condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medical records have not been met. Therefore, we decided that the Plan does not have to pay for medical records to be sent from one facility to another facility.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from August 17, 2019 to October 23, 2019.
You asked the Plan to pay for home health services. You say that you were not able to receive the services you needed from participating providers. The Plan denied your request. The Plan says services provided by non-participating providers are not covered.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The provider you received these services from does not participate in Medicare. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from August 17, 2019 to October 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on October 30, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that you confirmed the member's benefits and believe that non-emergency transport is a covered benefit if medical necessity is met. The Plan denied your request. The Plan says they have no record of the non-participating provider calling to verify member benefits and coverage.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our physician reviewer found the documentation does support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on October 30, 2019. The documentation does support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on October 30, 2019. The patient had a diagnosis of dementia with behavioral disturbance and was being transported from medical facility to a new medical facility for psychiatric treatment. There was a documented risk for elopement. The documentation does not support that the ambulance transport on October 30, 2019 was medically reasonable and necessary 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 non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting.
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 the enrollee is currently undergoing treatment at an ACH for a wound infection following a transmetatarsal amputation. The enrollee is receiving wound care and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 4, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on April 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 27, 2019.
You asked the Plan to waive the copayment for the ER visit. You say that all charges were covered for your previous visits. You say that you are owed $50. The Plan denied your request. The Plan says the $50 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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for the ER visit. The ER visit falls within the "Emergency 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 ER visit provided on November 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an abdomen x-ray (74021) provided on January 21, 2020 by the provider.
You asked the Plan to waive the copayment for the abdomen x-ray. You say that you should not be responsible for the entire copayment since the only place in your area for imaging services is the hospital. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $90 copayment for basic radiological services performed in an outpatient hospital setting. You have been asked to pay $90 for the abdomen x-ray. 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 abdomen x-ray (74021) provided on January 21, 2020 by the provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 27, 2019 to April 28, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary care.The Plan denied your request. The Plan says this is approved only as outpatient observation. Also, the facility did not request authorization for inpatient care to be provided after the enrollee was stabilized which is required.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was a then 94 year old female with a history of stroke and atrial fibrillation who was brought to the ED on 4/27/19 on due to weakness and near syncope. In the ambulance, her blood pressure was 85/50. In the ED, her exam was normal. She was treated with IV fluids and admitted to telemetry. Her Nortriptyline was held. Her condition stabilized and improved and she was discharged home on 4/28/19 with outpatient PCP follow-up. The review has determined that the record did not show that at the time of inpatient admission (1725 on 4/27/19) the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from April 27, 2019 to April 28, 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 the portable tanks run out and make it hard for you to go anywhere.The Plan denied your request. The Plan says you have a stationary oxygen concentrator and portable tanks that meet your needs 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 stationary 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the durable medical equipment provided on October 17, 2019.
You asked the Plan to waive the deductible for the durable medical equipment. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received durable medical equipment on the date of service at issue in this appeal. The Plan says the correct amount has applied towards your deductible per your contract with the Plan.
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 $500 deductible before the plan will pay their share for Durable medical equipment. You have been asked to pay $500 deductible that must be met before the plan will pay their share for the durable medical equipment. The durable medical equipment falls within the Durable medical equipment 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 deductible for the durable medical equipment provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveContour Next test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that the requested brand test strips are higher ranked based on consumer review and more accurate.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 strips have not been met.Therefore, we decided that the Plan does not have to pre-approveContour Next test strips.