Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excision of torus mandibularis.You asked the Plan to pre-approve the excision of torus mandibularis. You say that the enrollee has a torus anterior to her region of osteomyelitis which will prevent the enrollee from comfortably wearing a dental prosthesis.The Plan denied your request. The Plan says neither Medicare nor the enrollee's plan covers this service.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approve the excision of torus mandibularis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided on August 23, 2019 and October 11, 2019.You asked the Plan to waive the copayment for wound care. You say that you previously had these services and were charged less. You say that you weren't given a reason for the costs.The Plan denied your request. The Plan says the copayments 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 $125 for each Medicare-covered in-network outpatient hospital facility visit. You have been asked to pay a total of $250 for wound care. Date of Service Service Standard Copayment Member Liability August 23, 2019 Wound Debridement $125 $125 October 11, 2019 Compression System Application $125 $125 TOTAL: $250 Wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the wound debridement and compression system application was provided by the hospital. 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 wound care provided on August 23, 2019 and October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound, myocardial perfusion imaging, and aninpatient hospital stay from October 1, 2019 to October 22, 2019.You asked the Plan to waive the copayments foran ultrasound, myocardial perfusion imaging, and 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 $360 copayment each day for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $100 copayment for each radiological diagnostic service. You had an ultrasound on October 1, 2019. Therefore, you are responsible to pay the $100 copayment. You had a myocardial perfusion imagingon October 1, 2019. Therefore, you are responsible to pay the $100 copayment.You had an inpatient hospital stay from October 21, 2019 to October 22, 2019. Therefore, you are responsible to pay the $360 copayment. The total amount you owe is: $560.You have been asked to pay the totalcopayment amount of $560 for an ultrasound, myocardial perfusion imaging, and an inpatient hospital stay. An ultrasound and myocardial perfusion imaging fall within the inpatient hospital care benefit category. An inpatient hospital stay 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 copayments foran ultrasound, myocardial perfusion imaging, and an inpatient hospital stay from October 1, 2019 to October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forpractitioner visit. You say that your provider provided medically necessary services in good faith.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the service was not referred by an in-network provider.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 forthe medical services provided on September 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 4, 2019.You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up appointment and should not be charged the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for provider and professional services at an in-network specialist's office visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits benefit category.Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a procedure.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the guided tissue regeneration (D4266), and the bone replacement graft for ridge preservation (D7953) provided on October 25, 2019.You asked the Plan to pay the in network rate for the dental services. You say that the Plan recommended you see a pediatric endodontist to receive the service. You say that there are no in-network dentists in your area. You also say that your in-network dentist recommended another office.The Plan denied your request. The Plan says the dental services you received are not listed as 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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pay the in network rate forthe guided tissue regeneration (D4266), and the bone replacement graft for ridge preservation (D7953) providedon October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer tub rail.
You asked the Plan to pre-approve a transfer tub rail. You say that you have limited movement and the safety
bar would prevent a slippery fall. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because
they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a transfer tub rail.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair electronic connection.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311). You say that the
enrollee needs to control the power options through the joystick. The Plan denied your request. The Plan says
the enrollee's upper strength is adequate for controlling the power options using their own switches.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
Documentation shows that the enrollee has normal range of motion and 5/5 strength in the bilateral upper
limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power
options using their own switches which are included in the allowance of these power options. Therefore, we
decided that the Plan does not have to pre-approve the power wheelchair Electronic connection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe implant removal provided on October 15, 2019.You asked the Plan to waive the copayment forthe implant removal. You say that this should have been included with the surgical fees. You say that you should not be charged for the 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). Your contract with the Plan clearly says that you must pay a $25 copayment per visit for Medicare-covered specialty care services. Covered services include medically-necessary medical care or surgery services furnished in a physician's office. You have been asked to pay a $25 copayment for the implant removal. The implant removal falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up to a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe implant removal provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips.You asked the Plan to pre-approvethe non-preferred brand of test strips. You say that the enrollee is using OneTouch Ultra test strips.The Plan denied your request. The Plan says a non-preferred meter and test strips must be deemed medically necessary for the member by a healthcare provider.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. There is nodocumentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea hammertoe correction (28285).You asked the Plan to pre-approvea hammertoe correction. You say that this procedure should alleviate the enrollee's problem indefinitely.The Plan denied your request. The Plan says no other treatments have been tried.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 a hammertoe correction. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, there is no evidencethat the enrollee had failed to improve with shaving of the corn, had a significant functional deformity, or had tried and failed other reasonable non-operative treatment to support the medical necessity of proceeding with arthroplasty at this time. Therefore, this request for foot surgery (CPT code 28285) is not medically reasonable and 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 a hammertoe correction have not been met.Therefore, we decided that the Plan does not have to pre-approvea hammertoe correction (28285).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on November 8, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that this was a follow-up to your previous emergency room visit. You say that you shouldn't be charged a copayment. 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 $90 copayment per emergency room visit within or outside the service area. You have been asked to pay $50, which is less than the standard $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 ED visit provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September17, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that you rely on the hospital for authorization.The Plan denied your request. The Plan says utilization of network providers are required when available, and authorization for certain 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 onlyin 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. ThePlan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these out-of-network services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 16, 2019 to enrollee by an out of network (OON) 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 forthe medical services provided on September 16, 2019 to enrollee by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual adult tilt in space wheelchair and accessories.
You asked the Plan to pre-approve a manual adult tilt in space wheelchair and accessories. You say that the custom wheelchair is necessary because the enrollee spends extended periods of time in a wheelchair. The Plan denied your request. The Plan says the enrollee resides in a long-term care facility which is required to provide this equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a manual adult tilt in space wheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a manual adult tilt in space wheelchair and accessories.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 13, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that it was time for your colon exam. You say that you don't have a $325 copayment. 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 surgical services at an in-network outpatient hospital facility. You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes and polyps were removed which is considered a surgical procedure.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an intravitreal injection and does not have to waive the coinsurance for a Medicare Part B drug injection provided by the hospital on July 19, 2019.You asked the Plan to waive the copayment for an intravitreal injection and to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the increase in 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 $400 copayment for outpatient hospital surgery services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.You received an intravitreal injection on July 19, 2019. An intravitreal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $309.35, which is less than the $400 copayment. You received a Medicare Part B drug injection on July 19, 2019. The allowed amount is $1,440.61 and 20% of that is $288.12. The total amount you owe is: $597.47. You have been asked to pay the total amount of $597.47 for an intravitreal injection and a Medicare Part B drug injection. An intravitreal injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 intravitreal injection and does not have to waive the coinsurance for a Medicare Part B drug injection provided by the hospital on July 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips for the enrollee.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that thisis not a preferred strip for the Plan.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.The items at issue are OneTouch Ultra Blue test strips. OneTouch Ultra Blue is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers.Therefore, we decided that the Plan does not have to pre-approveOneTouch Ultra Blue test strips for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from October 22, 2019 to March 16, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plandoes not have to pre-approveskilled nursing facility (SNF) care.