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

We decided that the Plan does not have to pre-approve a Resmed Airsense 10 autoPAP CPAP device.
You asked the Plan to pre-approve a replacement CPAP device. You say that the enrollee's current CPAP device turns off in the middle of the night. The Plan denied your request. The Plan says the records do not show the CPAP device is not working correctly or cannot be repaired.
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. The enrollee's current CPAP device is less than 5 years old. The notes from the Respiratory Care Practitioner show the CPAP device is working properly. Based on this information, we decided that Medicare rules for coverage of a replacement CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement CPAP device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the specialist services rendered on August 15, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you do not feel responsible for the charges. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for Medicare-covered specialist services received in a network provider's office.
Review of the file shows that you received specialist services on August 15, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $66.30. These services fall within the Medicare-covered specialist services received in a network provider's office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the specialist services rendered on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 3, 2019.
You asked the Plan to waive the copayment for these services. You say that you do not feel you should have to pay the full copayment. The Plan denied your request. The Plan says the copayment was 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 $225 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.
Review of the file shows that you received outpatient surgical services on December 3, 2019. Per your contract with the Plan, there is a $225 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $217.68. Given that the allowed amount was less than the $225 copayment, you have been asked to pay $217.68 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement grafts (D7953x2) provided by on August 27, 2019.   
 
You asked the Plan to issue reimbursement for the bone replacement grafts. You say that you were referred by your dentist as a medical necessity for oral surgery; therefore, you feel the services should be covered by the Plan. The Plan denied your request. The Plan says the services provided are not a covered benefit under your policy. 
 
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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement grafts (D7953x2) provided on August 27, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the sleep study rendered on December 12, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you were unable to complete the study. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for sleep studies.
Review of the file shows that you received a sleep study on December 12, 2019. The file shows that the test was rendered for a total of 7 hours and 51 minutes. You have been asked to pay a 20% coinsurance for these services. These services fall within the sleep studies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the sleep study rendered on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build-up for tooth 3 (D2950).
You asked the Plan to pre-approve the dental service. You say that the enrollee is in severe pain and the
services are necessary alleviate pain and allow him to eat and digest food properly. The Plan denied your
request. The Plan says this service is not covered under the plan benefits.
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. Services not listed is not
covered by the plan.
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 the
core build-up for tooth 3 (D2950).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from May 16, 2019 to May 31, 2019.
You asked the Plan to pay for the services. You say that there is a $5,000 per year limit for private nursing duty that has not been met. The Plan denied your request. The Plan says the services were rendered by a provider not certified with Medicare.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. The rendering provider is not eligible to bill Medicare. The plan did not pre-approve the services. We found no exception that would require the plan to pay for these items/services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided from May 16, 2019 to May 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dentures. You say that you need replacement dentures as you have lost yours previously at the end of October. You also say that you have a number of medical conditions which require sufficient nutrition; however, you are unable to eat and have lost a great amount of weight. The Plan denied your request. The Plan says you have exhausted your allowable benefit as you have received a complete upper and lower denture in 2018.  
 
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.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Specifically, your request exceeds the allowable benefit as you have previously received a complete set of dentures provided on December 17, 2018. The Plan benefit allows for a complete set of dentures once every five years. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
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 on October 4, 2018.
You asked the Plan to pay for these services. The Plan denied your request. The Plan says that this is not a
covered benefit under Medicare and the Plan.
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 on October 4, 2018.
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 September 30, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same durable medical equipment on March 12, 2018. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably
damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oncology services to be provided by the out of network provider. 
 
You asked the Plan to pre-approve the oncology services. You say that you were advised that your referral should have been granted based on the contractual relationship. You also say that you were advised by the physician that you would be able to choose the provider you received services from. The Plan denied your request. The Plan says the requested services are available within 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 pre-approve 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. 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 the oncology services to be provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and leg garment
(E0667).
You asked the Plan to pay for a pneumatic compression device and garment. You say that you respectfully
disagree with this determination and ask that you re-evaluate the denial with the enclosed clinical
documentation supporting medical necessity of the requested equipment. The Plan denied your request. The
Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed
four week trial of a basic pneumatic compression device of either 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 pay for a pneumatic compression device
(E0652) and leg garment (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog injection services.
You asked the Plan to pre-approve the Novolog injection services. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is self-administered. The plan says that PPO does not include a pharmacy or drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog injection services.
Benefits for the Novolog injection services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a Group 1 power operated vehicle.
You asked the Plan to provide a Group 1 power operated vehicle. You say that a POV is recommended. The Plan denied your request. The Plan says the records show the enrollee is capable of performing MRADLs in the home using a walker.
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 does not show that the enrollee has a mobility deficit that impairs their participation in MRADLs, or that the enrollee can safely operate the PMD being requested. The file shows the enrollee's condition can be improved by a walker. There is no home assessment documentation. This means that Medicare rules for coverage of a PMD have not been met. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to provide a Group 1 power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 18, 2019 to August 15, 2019 by out of network provider. 
 
You asked the Plan to pay for osteopathic manipulative treatment (98929) provided on June 18, 2019 through August 15, 2019. You say that you would like reconsideration as there were no osteopathy doctors in-network. The Plan denied your request. The Plan says you did not receive authorization for these services and there are providers in-network who provide osteopathic manipulative treatment. 
 
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 June 18, 2019 to August 15, 2019 by out of network provider.  
 
Your complaint about the Plan being unable to find a network provider qualified to render these services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the anesthesia, and an endoscopy provided on August 14, 2019.
You asked the Plan to waive the deductible for the anesthesia and the endoscopy. You say that you would like the provider to pay for the services in full. You say you were diagnosed with Barrett's Esophagus and it needs to get checked every year. 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. Your contract with the Plan says that there is a $750 deductible that applies towards outpatient surgery and/or services at an outpatient hospital facility. The anesthesia and the endoscopy you asked the Plan to waive the deductible for falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards outpatient surgery and/or services at an outpatient hospital facility. This cost sharing is a contractual obligation that had not been met at the time the anesthesia and the endoscopy were received on August 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the anesthesia and the endoscopy provided August 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided from September 29, 2019 to October 1, 2019.
You asked the Plan to waive the copayment for an observation stay. You say that you are unhappy with the
care received and feel the stay was unnecessary. 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 $250
copayment for observation services.
You have been asked to pay a $250 copayment for an observation stay. An observation stay 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 an
observation stay provided from September 29, 2019 to October 1, 2019.
Your quality of care concerns have been handled separately by the health plan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from October 3, 2018 to October 5, 2018.
You asked the Plan to waive the copayment. You say that you should not owe the copayment as it took the plan one year to process the claim. The Plan denied your request. The Plan says the copayment has been applied correctly for the inpatient hospital care provided. Cost sharing is a contractual obligation under the plan and cannot be waived.
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 copayment for each Medicare-covered hospital stay. You have been asked to pay a $132.16 copayment for the inpatient hospital care. The plan benefit for inpatient hospital care states that there is a $500 copayment for each Medicare-covered hospital stay. However, you had met your out of pocket maximum at that time and was only assessed a $132.16 copayment. 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 care provided October 3, 2018 to October 5, 2018.