Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 25, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says no authorization was obtained, and the services are not considered medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the documentation in the medical records does not support that Guardant360 molecular diagnostic testing was medically reasonable and necessary for the enrollee in this case, or that it would impact her management and outcome. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the glimepiride, lisinopril, meloxicam, metformin, metoprolol tartrate and simvastatin provided from August 10, 2019 to August 12, 2019.
You asked the Plan to pay for these drugs. You say that you were brought medications by nurses. The Plan denied your request. The Plan says that these drugs are not covered by the 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 pay for the glimepiride, lisinopril, meloxicam, metformin, metoprolol tartrate and simvastatin provided from August 10, 2019 to August 12, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from May 4, 2019 through May 11, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that he was discharged from the first visit with an infection and blockage. You say that you shouldn't be responsible for the second visit. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $290 copayment per day, days 1 to 5 at an in-network outpatient hospital. Your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility type. The enrollee has been asked to pay a $1,450 copayment for the inpatient stay. ($290/day x 5 days = $1,450). The inpatient stay falls within the "Inpatient hospital care" benefit category. 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 for the inpatient stay provided from May 4, 2019 through May 11, 2019.
Your complaint about your coverage being a joke 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 21, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for each visit with a primary care provider. The medical records show that received services beyond an annual wellness visit on October 21, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 copayment for an office visit. An 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 an office visit provided on October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes provided on May 25, 2019 by the physician.
You asked the Plan to pay for hospital discharge day management; more than 30 minutes. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Specifically, no discharge summary was provided. The services are not able to be corroborated. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management; more than 30 minutes have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes provided on May 25, 2019 by the physician.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 6, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on June 25, 2019.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions for a medical condition of the eye are not covered.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. We looked at the file and Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided from July 23, 2019 through July 24, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.
You were referred for inpatient hospital care by Lake Granbury Medical Center. Lake Granbury Medical Center is a contract provider. The file does not show that the Plan provided notice that inpatient hospital care would not be covered. Under Medicare rules, this means inpatient hospital care is considered approved by the Plan. Therefore, we decided that the Plan has to pay for inpatient hospital care provided from July 23, 2019 through July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 21, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you went to get your feet clipped. You say that you thought you did not have a copayment for this service. 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 $20 copayment for each Medicare-covered in-network visit for medically necessary foot care. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Podiatry services" benefit category. The records show that the office visit was for an initial evaluation for painful mycotic nails. 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 August 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast augmentation and a gender-affirming surgical procedure.
You asked the Plan to pre-approve these services. You say that the procedures will alleviate gender dysphoria. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you underwent chest masculinization surgery and have legally changed your name and gender marker. You are now seeking breast augmentation, hair removal, and possible voice feminization surgery. The note dated July 18, 2019 states that you identified as male. Your therapist noted on November 7, 2019 that he did not agree with your treatment plan. There is no consistent medical documentation to support that the requested procedures are medically necessary at this time. Permanent gender-affirming procedures are not medically reasonable and necessary without documented consistent gender identity 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve breast augmentation and a gender-affirming surgical procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for an eye exam provided on June 25, 2019 and eyeglasses provided on July 17, 2019.
You asked the Plan to reimburse you for the eye exam and the eyeglasses. You say you do not like the quality of the eyeglasses that another practice provides. You say that this provider has been taking care of your vision for many years and you trust her. The Plan denied your request. The Plan says you must use a network optical provider. 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a network optical provider. We looked at the file and the Plan's rules. The requested providers in this case are not a network providers with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eye exam and the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for an eye exam provided on June 25, 2019 and eyeglasses provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by out of network provider.
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 the services were rendered by a non-participating 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 for the medical services provided on August 14, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for SNF care has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the programming device evaluation rendered to you on September 30, 2019.
You asked the Plan to waive the copayment for these services. You say that you would like the copayment waived as part of the physician visit. 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 $20 copayment for other outpatient diagnostic tests from an in-network specialty physician.
Review of the file shows that you received outpatient diagnostic testing on September 30, 2019. You have been asked to pay a $20 copayment for these services. These services fall within the other outpatient diagnostic tests from an in-network specialty physician 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 programming device evaluation rendered to you on September 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 15, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told the Plan did not cover all the bill because they did not authorize the ambulance service. The Plan denied your request. The Plan says the transportation was medically indicated and covered. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment per one-way trip for all other members of the Southern California Region. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on May 22, 2019.
You asked the Plan to pay for foot orthotics. You say that your previous health plan paid for orthotics and you were unaware this Plan would not. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) sensor rendered to L. Witherspoon by Minimed Distribution Corporation on March 18, 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 the code is not covered.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. The rules say that procedure code A9276 (sensor) describes the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. The services at issue are a sensor billed with code A9276. This code is for a sensor for a non-therapeutic CGM, which is not covered by Medicare. Therefore, we decided that the
Plan does not have to pay for the continuous glucose monitor (CGM) sensor rendered to L. Witherspoon by Minimed Distribution Corporation on March 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0650).
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0650).
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the diagnostic mammogram. We decided that the Plan does not have to waive the copayment for the ultrasound.
You asked the Plan to waive the copayment for the diagnostic mammogram and ultrasound. You say that the Evidence of Coverage does not state that an additional screening as a follow up falls under a new category for coverage. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the copayment for the diagnostic mammogram.
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 other outpatient diagnostic tests at an in-network outpatient hospital facility.
The Plan says that you must pay $117.53 for the mammogram. Based on the Plan contract, however, you cannot be asked to pay more than $10 for the mammogram. Therefore, we decided that the Plan has to reduce the copayment for the mammogram.
We also decided that the Plan does not have to waive the copayment for the ultrasound.
The allowed amount for the ultrasound is $61.31. You have been asked to pay $61.31, which is less than the standard $75 copayment for the ultrasound. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 11, 2019 by an out of network provider.
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 the services were rendered by a non-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 for the medical services provided on July 11, 2019 by the out of network provider.