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

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on August 30, 2019.You asked the Plan to waive the copayment for the colonoscopy. You say that your doctor ordered a crucial colonoscopy and endoscopy. You say that the denial should be reconsidered.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 $325 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that the Plan paid $446.09, leaving a member responsibility of $325. 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 colonoscopy provided on August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

You asked the Plan to pre-approve parenteral nutrition solution (B4185). You say that the enrollee is suffering from severe protein-calorie malnutrition due to hemodialysis.The Plan denied your request. The Plan says the enrollee has a functioning gastrointestinal tract.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. Based on this information, we decided that Medicare rules for coverage of parenteral nutrition solution (B4185) have not been met.Therefore, we decided that the Plan does not have to pre-approveparenteral nutrition solution.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you are currently functioning at your normal level of function.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0150), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on August 1, 2019 by out of network provider.You asked the Plan to pay for the dental services. You say that you called your insurance plan because your regular dentist was out of network. You say that you were given 3 different in network dentists.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that dental services must be received from a contracted dental provider in order to be 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 dental services you received are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay for the oral exam (D0150), the prophylaxis (D1110), and the bitewing x-rays (D0274) provided on August 1, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve testosterone cypionate (J1071).
You asked the Plan to pre-approve testosterone cypionate. You say that the enrollee needs to continue this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription 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 testosterone cypionate (J1071).
Benefits for testosterone cypionate 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 pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 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 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 fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on December 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis for the enrollee.You asked the Plan to pre-approve this drug. You say that the enrollee has a diagnosis of atrial fibrillation and has failed Xarelto secondary to gastrointestinal bleeding.The Plan denied your request. The Plan says that this is not covered under Part B.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 Eliquis for the enrollee.Benefits for this drug 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital visit provided by a participating provider on December 5, 2019 and December 12, 2019.You asked the Plan to waive the copayment for an outpatient hospital visit. You say that you should not be charged a facility fee. 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 $325 copayment for outpatient hospital services/in-network/non-surgical visit in an outpatient clinic. You have been asked to pay less than your $325 copayment for each outpatient hospital visit. The total amount you are being asked to pay is $278.24 ($139.12 x 2 visits = $278.24). A facility fee can be applied when services are provided in an outpatient hospital setting; therefore, the correct copayments have been applied. An outpatient hospital visit falls within the outpatient hospital services/in-network/non-surgical visit in an outpatient clinic 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 outpatient hospital visit provided by a participating provider on December 5, 2019 and December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 24, 2020.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 fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP and supplies provided on June 21, 2019 and September 24, 2019.You asked the Plan to pay for the CPAP and supplies. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the CPAP was submitted with the wrong modifier and the supplies and there is no itemized delivery ticket to indicate what specific supplies were provided.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 thiscase. The only Delivery Ticket provided does not have a carrier tracking number and there is no Proof of Delivery for either date of service. Therefore, we decided that the Plan does not have to pay for the CPAP and supplies provided on June 21, 2019 and September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator (POC). You asked the Plan to pre-approve a POC. You say that you cannot carry your current oxygen concentrator.The Plan denied your request. The Plan says that your request is not a covered benefit because Medicare does not cover purchased oxygen equipment, your provider did not order this device for you and your oxygen needs can be provided by rental of approved equipment.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 rules also say that purchased oxygen equipment is statutorily non-covered.The record shows that your physician did not order the POC for you. The record also shows you would like to purchase the POC and not rent it.Therefore, we decided that the Plan does not have to pre-approve an Inogen portable oxygen concentrator (POC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on
May 2, 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 rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary
and conducted a face-to-face assessment. Therefore, we decided that the Plan does not have to pay for an anklefoot
orthosis (L1971) provided to the enrollee on May 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance balance lens (V2700) progressive lens (V2781) frames (V2020) non-covered item (A9270) sales tax (S9999) purchased December 17, 2019.You asked the Plan to waive the coinsurance the vision services. You say that you are requesting an additional $140.14 reimbursement. You were misinformed by the plan representatives. Had you known you would not be reimbursed in full you would have gone to an in-network provider.The Plan denied your request. The Plan says the claim processed and reimbursed correctly. The enrollee is responsible for the 45% out of network coinsurance amount. Sales tax is not a covered item.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 45% coinsurance for non-Medicare covered eyewear received from an out-of-network provider. You have been asked to pay $140.20 for the vision services. The vision services fall within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance balance lens (V2700) progressive lens (V2781) frames (V2020) non-covered item (A9270) sales tax (S9999) purchased December 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 3, 2020.You asked the Plan to waive the copayment for the ultrasound. You say that you haven't paid this much for the service before. You say that you weren't informed it would cost so much.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 $150 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). You have been asked to pay $93.33, which is less than the standard $150 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 ultrasound provided on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.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,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on November 4, 2019.You asked the Plan to pay for the orthoses. 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851,L2397) provided to the enrollee on November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide Dysport injections.You asked the Plan to provide Dysport (J0586). You say that the enrollee suffers significantly and needs this drug.The Plan denied your request. The Plan says the drug is not helpful for treatment of the enrollee's health problem.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 provide Dysport (J0586). Our reviewer says that the drug is not medically necessary, reasonable or indicated. Our physician reviewer found based on the documentation provided that the health plan's denial should be upheld.  The enrollee is suspected of having piriformis syndrome, for which botulinum injections have been requested.  It is noted that the enrollee has not had a hands-on examination from a provider. It is noted that the enrollee has not yet completed a course of recommended physical therapy. As such, the documentation does not support that the requested injections are currently medically necessary, reasonable or indicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Dysport (J0586) have not been met.Therefore, we decided that the Plan does not have to provide Dysport injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit provided on December 19, 2019.You asked the Plan to pay for the annual wellness visit. The Plan denied your request. The Plan says you previously met your annual wellness visit limit on March 28, 2019.The contract with the Plan says that an annual wellness visit is covered once every 12 months. We looked at the file and the Plan's rules. The Plan covers an annual wellness visit once every 12 months. The file shows that the plan previously covered an annual wellness visit on March 28, 2019. Therefore, we decided that the Plan does not have to pay for an annual wellness visit provided on December 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amniotic membrane transplant services. You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there are other, more standard, options available.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 the requested services. Our physician reviewer found that you have a history of blepharitis, dry eye syndrome, and (epithelial) basement membrane dystrophy. Amniotic membrane transplant is used to repair and heal host corneal and/or conjunctival tissue as a graft and by providing growth factors and cytokines to promote healing. The main indications for this procedure include limbal stem cell deficiency, non-healing epithelial defects, graft for reconstruction of the conjunctival surface such as with pterygium excision. You have dry eye syndrome and epithelial basement dystrophy. Currently, there is no clinical indication to use Ambiodisk to treat either of these conditions.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve amniotic membrane transplant services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 10, 2020.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 topay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 10, 2020.