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

We decided that the Plan does not have to pay for a CGM monitor and supplies (K0554 and K0553) provided on January 8, 2020.
You asked the Plan to pay for the CGM monitor and supplies. You say that you would like reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a valid Proof of Delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the listed date of service is prior to the date of delivery. Therefore, we decided that the Plan does not have to pay for a CGM monitor and supplies (K0554 and K0553) provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist/hand orthosis rendered on December 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 the services were 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the submitted documentation does not contain an appropriate history and a physical examination of the wrists. This documentation is required to adequately assess whether the wrist/hand orthoses were medically reasonable and necessary. The progress notes dated November 11, 2019 do not document any wrist pain. The records do not support that the wrist/hand orthosis was medically necessary. 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 pay for the wrist/hand orthosis rendered on December 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 19, 2019 to December 23, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford 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 $225 copayment per day for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from December 19, 2019 to December 23, 2019. Therefore, you are responsible to pay the $225 copayment for days 1-4 (December 19, 2019 to December 22, 2019). $225 (copayment) x 4 (inpatient days) = $900. You have been asked to pay the total copayment amount of $900 for an inpatient hospital stay. An 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 an inpatient hospital stay provided from December 19, 2019 to December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, periodic oral evaluation, two first intraoral periapical x-rays, additional intraoral periapical x-ray, bitewings, prophylaxis, and topical application of fluoride - excluding varnish provided on December 10, 2019 and December 19, 2019.
You asked the Plan to pay for the dental services. You say that these services were preventive and provided by an out-of-network provider. The Plan denied your request. The Plan says services provided by non-participating providers are not covered.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, periodic oral evaluation, two first intraoral periapical x-rays, additional intraoral periapical x-ray, bitewings, prophylaxis, and topical application of fluoride - excluding varnish provided on December 10, 2019 and December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the progressive lens (V2781), polycarbonate lens (V2784), anti-reflective coating (V2750), and miscellaneous vision service (V2799) provided on November 18, 2019.You asked the Plan to issue reimbursement for the eyeglass lenses. You say that you are requesting a reconsideration of the Plan's denial as it was necessary to get new lenses due to changes in your eye health over the past year.The Plan denied your request. The Plan says that your request for reimbursement exceeds the allowable vision benefit.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. 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 these services have not been met.Specifically, you previously received eyeglasses on March 26, 2018. Your request for reimbursement exceeds the allowable Plan benefit as payment is limited to$200 every two years. Additionally, you do not meet criteria for coverage as you have not had a recent cataract surgery.Therefore, we decided that the Plan does not have to issue reimbursement for the progressive lens (V2781), polycarbonate lens (V2784),anti-reflective coating (V2750), and miscellaneous vision service (V2799) provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SoClean device for the enrollee.You asked the Plan to pre-approve the device. You say that this is needed to help keep the breathing machine clean.The Plan denied your request. The Plan says Medicare does not cover routine cleaning of equipment, nor does it cover hygienic devices as they are not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve the SoClean device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. 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 pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services for a second opinion.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says out-of-network providers are allowed only when the service is medically necessary but unavailable within the network or when an emergency.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services for a second opinion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on December 26, 2019.
You asked the Plan to pay for the orthoses and sleeves. The Plan denied your request. The Plan says that the billed supply code cannot be verified.
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 orthoses and sleeves. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. On 12/12/19, the enrollee reported no joint pain, swelling, or deformity on the review of systems. Examination of the knees showed no tenderness, no swelling, and no crepitation with a full range of motion. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these items.
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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on December 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eszopiclone 3mg tablet.
You asked the Plan to pre-approve Eszopiclone 3mg tablet. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Eszopiclone 3mg tablet.
Benefits for Eszopiclone 3mg tablet 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 pre-approve a power seat elevation system for the enrollee.
You asked the Plan to pre-approve the elevator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty scooter. You asked the Plan to pre-approve a heavy duty scooter. You say that you need a power wheelchair to get around. The Plan denied your request. The Plan says that you do not meet the weight requirements for this power mobility device. The Plan must follow Medicare rules. Medicare rules say that the weight capacity for a heavy duty power operated vehicles is 301 to 450 pounds. We looked at the file and Medicare rules. The file does not show that you weigh between 300 and 450 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy duty scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty scooter. Please note, the Plan has approved a group 1 standard power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee has no clinical reason why he cannot use a regular blood glucose monitor.The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under certain medical indications. 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 requested device. Our physician reviewer found that the enrollee is noted to be a Type II diabetic, who uses both oral medication and set-dose insulin to control his blood sugar. The enrollee is noted to have a CGM, but it is unclear how often he is actually checking blood glucose values. While the enrollee's insulin dose has been increased over the last few months, there is no evidence that the enrollee is using blood glucose monitoring to self-adjust insulin dosages multiple times a day. Therefore, the requested CGM is not shown to be medically necessary or reasonable.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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on January 20, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you disagree with the specialist charges because you need to have a catheter removed every 30 days. 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 $50 copayment for each specialist visit. You have been asked to pay a $50 copayment for specialist services. Specialist services fall 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 specialist services provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on October 22, 2019.
You asked the Plan to pay for the services. You say that the enrollee self-referred, so this should be reconsidered. The Plan denied your request. The Plan says the services were not authorized by network/primary care providers.
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 office visit services provided to the enrollee on October 22, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the services provided to you from November 6, 2019, to November 8, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the documentation does not support the billed services. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules also 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 provider in question is a contract provider. The file does not show that the Plan provided notice that these services would not be covered. Under Medicare rules, this means that the services are considered approved by the plan. Additionally, the Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The file does not contain medical records for the dates of service in question from the contract provider. It is the plan's responsibility to obtain and provide records from contract providers. Therefore, we decided that the Plan has to pay for the services provided to you from November 6, 2019, to November 8, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on October 30, 2019.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a diagnostic colonoscopy on the date of service at issue in this appeal. The Plan states the correct copayment has applied 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 $250 copayment for Outpatient diagnostic tests. A screening colonoscopy is a procedure done for a patient who has no symptoms of colon cancer. A diagnostic colonoscopy is done when a patient has related symptoms or has a polyp removed during the procedure. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a diagnostic colonoscopy on October 30, 2019. You have been asked to pay a $250 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the Outpatient diagnostic tests 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 diagnostic colonoscopy provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you did not call for this ambulance and did not need medical help.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 3, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these services.
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 services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Respironics EverFlo oxygen concentrator purchased on April 1, 2019.You asked the Plan to pay for the oxygen concentrator. The Plan denied your request. The Plan says that purchased oxygen equipment is not covered.The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered.Therefore, we decided that the Plan does not have to pay for the Respironics EverFlo oxygen concentrator purchased on April 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 2, 2019 by a non-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 August 2, 2019 by a non-network provider.