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

We decided that the Plan does not have to waive the copayment for the office visit provided on February 21, 2020. You asked the Plan to waive the copayment for the office visit. You say that you paid $35 out-of-pocket. You say that you should be refunded. 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 $10 copayment for each in-network primary care provider visit for Medicare-covered services. You have been asked to pay a $10 copayment for the office visit. The 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 office visit provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the BiPAP supplies provided on July 3, 2019 to December 28, 2019 by an out of network provider.
You asked the Plan to pay for the BiPAP supplies. You say that the Plan should pay for the supplies. The Plan denied your request. The Plan says Medicare paid the claim and assessed a coinsurance of 20% of the eligible reimbursement rate.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you can get care from out-of-network providers and pay 20% coinsurance. 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 at issue in this appeal. The items were provided by an out-of-network provider. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the BiPAP supplies provided on July 3, 2019 to December 28, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive or reduce the copayment for an inpatient hospital stay provided by a network facility on May 16, 2019 to May 30, 2019.
You asked the Plan to waive or reduce the copayment for an inpatient hospital stay. You say that there was no mention of this charged when you were admitted to this network facility. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to pay a $300 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,500 ($300 x 5 days = $1,500). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 or reduce the copayment for an inpatient hospital stay provided by a network facility on May 16, 2019 to May 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids You asked the Plan to pre-approve hearing aids. You say that you are being denied authorization to have a hearing aid and you don't think that this is fair. You would like to get help to get a hearing aid. There is no way you can buy one at the costs they are.The Plan denied your request. The Plan says this service is not covered under the plan benefits.The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services.Therefore, we decided that the Plan does not have to pre-approve hearing aids
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sanitizing equipment or hygienic supplies. You asked the Plan to pay for hygienic supplies. You say that this equipment is medically necessary and should be covered by the Plan.The Plan denied your request. The Plan says hygienic supplies are not covered by Medicare or the Plan.The Plan covers all items that Medicare covers. Medicare rules state that hygienic supplies are not covered. While this equipment may be appropriate for your use, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay for sanitizing equipment purchased July 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the fine needle biopsy provided on August
13, 2019.
You asked the Plan to waive the copayment for the fine needle biopsy. You say that you sent your bill for
review. You say that you were informed you didn't have to pay anything. 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 $200
copayment for all other Outpatient Services including observation and outpatient surgical services not provided
in an ambulatory surgical center.
You have been asked to pay a $200 copayment for the fine needle biopsy. The fine needle biopsy falls within
the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The fine needle biopsy is considered a 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 fine needle biopsy provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you would like reconsideration as
this service was medically necessary. The Plan denied your request. The Plan says the documentation reflects
that this was not an emergency and that there are in-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 for the medical services provided on January 15, 2020
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 4, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for the out of network psychotherapy services. You say that you have been going to
this public agency for months to receive psychotherapy and case management for your mental condition. You
say that the claim should be reprocessed and paid. The Plan denied your request. The Plan says the provider is
outside of the enrollee's network of providers and prior authorization was not obtained from the plan.
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 psychotherapy services provided on February 4,
2020 by an out of network (OON) provider.
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 this provider performed your surgery. You say that you do not want to get care from any other doctor. The Plan denied your request. The Plan says this provider is out-of-network. The Plan says that there are in-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 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30mg Isosorbide Mononit tablets.
You asked the Plan to pre-approve the Isosorbide Mononit. You say that you would like reconsideration
because this drug is medically necessary for treatment of the member's condition. The Plan denied your
request. The Plan says drug coverage for the member is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 30mg Isosorbide Mononit
tablets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections (J7325).
You asked the Plan to pre-approve Synvisc-One injections. You say that you believe Synvisc-One should be approved for the enrollee given her young age, failure of conservative treatment options, and growing evidence to support viscosupplementation for arthritis of the shoulder. The Plan denied your request. The Plan says this treatment is only approved for osteoarthritis of the knee. The Plan also says that the enrollee does not have osteoarthritis of the knee, and medical studies have not proven that these injections are helpful in joints other than the knee.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Synvisc-One injections. Our reviewer says that the Synvisc-One injections are not medically reasonable and necessary. Our physician reviewer found Synvisc-One injections are only medically acceptable for injection into the knee joint for osteoarthritis. Our reviewer also found that based on the medical records provided, the Synvisc-One injections (J7325) are not safe and effective or medically reasonable and necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections (J7325).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Positron Emission Tomography (PET) imaging (78815) with Axumin injection (A9588).
You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 PET scan. Our reviewer says that the PET scan is not medically necessary. Our physician reviewer found a PET Scan with Axumin indicated in men with suspected prostate cancer recurrence based on elevated PSA following prior treatment. This patient has new disease without previous treatment. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Positron Emission Tomography (PET) imaging (78815) with Axumin injection (A9588).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 8, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to help transport the patient to the unit and remain there until the patient is in stable condition. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for educational supplies (99071) provided on December 30, 2019.
You asked the Plan to pay for the educational supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99071 is included in the payment of the other services performed on the same date of service, for the same patient, and by the same provider and is not separately reimbursable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99071 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99071 has a status indicator of B. This means that payment for CPT code 99071 is bundled into payment for other services rendered. Based on this information, we decided that Medicare rules for coverage of the educational supplies have not been met. Therefore, we decided that the Plan does not have to pay for educational supplies (99071) provided on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for provider visit. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and out-of-network care was not needed while the enrollee was within the Plan's service area.
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 the medical services provided on October 9, 2019 by an out of network (OON) provider.
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 February 11, 2020 to February 18, 2020. You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are appealing the
denial of this claim. The Plan denied your request. The Plan says the claim did not deny and 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 $325
copayment per day, days 1 to 6 and a $0 copayment per day, days 7 to 90 at an in-network inpatient hospital. You have been asked to pay a $325 copayment for each day, days 1-6 of the inpatient hospital stay. ($325 x 6 = $1,950). The 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 the inpatient hospital stay provided from February 11, 2020 to February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. The enrollee may benefit from further physical and occupational therapy but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 4, 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 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 lumbar-sacral orthosis (L0650) provided to the enrollee on April 4, 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
January 16, 2020 to January 17, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that your copayment
amount is outrageous and you will not be paying this amount. 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 $300
copayment for each time you are admitted to an acute care hospital.
You have been asked to pay a $300 copayment for the inpatient hospital stay. The 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
the inpatient hospital stay provided from January 16, 2020 to January 17, 2020.