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

We decided that the Plan does not have to waive the copay for the ambulance services you received on August 28, 2019.
You asked the Plan to waive the copay for the ambulance services. You say that you did not ask for an ambulance. The Plan denied your request. The Plan says cost sharing is a contractual obligation and cannot be waived.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copay for each one-way Medicare-covered ground trip for ambulance services. You have been asked to pay a $200 copay for the ambulance services. The services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance services you received on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 16, 2019 to the 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-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 referring provider 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 October 16, 2019 to the enrolleel 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 home oxygen concentrator and a portable oxygen
concentrator.
You asked the Plan to pre-approve a home oxygen concentrator and a portable oxygen concentrator. You say
that you have been on oxygen but your portable machine has broken. The Plan denied your request. The Plan
says your medical records show that your oxygen levels are currently normal so the request cannot be approved
at this time.
The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or
arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a home oxygen concentrator and a portable oxygen concentrator have not been met. Therefore, we
decided that the Plan does not have to pre-approve a home oxygen concentrator and a portable oxygen
concentrator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on March 28, 2019.You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare pays for limited telehealth services.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 non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the genetic testing provided to the enrollee on March 28, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that there is a $500 deductible for all items and services, except those specifically excluded by the plan's contract. In-network specialist visits are not excluded from the deductible. You can find this information on pages 49 to 50 of the Plan's 2019 Evidence of Coverage (EOC). 
 
The Plan contract also says that enrollees must pay a $10 copayment for each in-network specialist's office visit. You can find this information on page 101 of the Plan's 2019 Evidence of Coverage (EOC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power wheelchair (K0010) provided on August 29, 2019.
You asked the Plan to pay for a power wheelchair. You say that you needed this wheelchair as quickly as
possible. The Plan denied your request. The Plan says this was provided by a provider that does not participate
in Medicare
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. The record shows that the provider that you purchased this item from
does not participate in Medicare. Based on this information, we decided that Medicare rules for coverage of a
power wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for a power
wheelchair (K0010) provided on August 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Levofloxacin tablet provided on September 17, 2019.
You asked the Plan to pay for the Levofloxacin tablet. You say that this medication was administered during a procedure. The Plan denied your request. The Plan says your medical benefit does not cover self-administered drugs.
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 Levofloxacin tablet provided on September 17, 2019.
Benefits for the Levofloxacin 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug screening provided to the enrollee on December 27, 2019.
You asked the Plan to pay for the drug screening. The Plan denied your request. The Plan says administrative drug screening testing is not a Medicare benefit for the diagnosis listed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the drug screening provided to the enrollee on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring
system.
You asked the Plan to pre-approve a continuous glucose monitor (K0553, K0554). You say that you have low
vision so it is hard to use a regular glucose monitor. The Plan denied your request. The Plan says you take oral
medicine and not insulin therefore the CGM is denied.
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.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a continuous glucose monitor (K0553, K0554) have not been met. Therefore, we decided that the
Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the specialist services rendered to you on August 7, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you were advised the services would have no out-of-pocket charges. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered specialist services.
Review of the file shows that you received specialist services on August 7, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the specialist services rendered to you on August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided October 9, 2019 to
October 16, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that the acute inpatient hospital admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on October 9, 2019 with generalized weakness. She was evaluated and found to have an abnormal urinalysis. The enrollee was then admitted and treated with IV fluids and antibiotics for a presumed urinary tract infection. She had an echocardiogram and received wound care for a Stage II sacral decubitus. Her condition improved and she was discharged to a skilled nursing facility on October 16, 2019 when she was considered medically stable. The review has determined that the record showed that at the time of the inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided October 9, 2019 to October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a toilet seat cushion.
You asked the Plan to pre-approve a toilet seat cushion. You say that a toilet seat cushion is necessary to
prevent a pressure ulcer. The Plan denied your request. The Plan says toilet seat cushions 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 Plan covers all items that Medicare covers. Medicare rules state that toilet seat cushions
are not covered because they are not primarily medical in nature.
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. While a toilet
seat cushion 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 toilet seat cushion.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 2, 2019.
You asked the Plan to pay for the lab services. You say that the Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy duty, extra wide hospital bed with weight
capacity more than 350 pounds, but does not exceed 600 pounds (E0303).
You asked the Plan to pre-approve the heavy duty hospital bed. You say that the railing is taller than the
mattress and the bed is very small and you cannot roll over in the bed The Plan denied your request. The Plan
says the enrollee does not meet the Medicare LCD criteria. The enrollee was also approved for a semi-electric
hospital bed with mattress and received 2/26/2020.
The Plan must follow Medicare rules. Medicare rules say that a heavy duty, extra wide hospital bed is covered
if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is
between 350 - 600 pounds. The records show that you weigh 268 pounds. Based on this information, we
decided that the Plan does not have to pre-approve the heavy duty, extra wide hospital bed with weight capacity
more than 350 pounds, but does not exceed 600 pounds (E0303).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like approval for these specialist
services. The Plan denied your request. The Plan says there are in-network providers available.
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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
specialist services to be provided by an out of network (OON) provider.
Please contact the Plan for a list of available in-network providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan has to pre-approve a partial lower denture(D5214).
You asked the Plan to pre-approve the dental service. You say that you do not have any upper teeth. You also say that you are missing 5 lower teeth on the right side and 4 lower teeth on the left side. The Plan denied your request. The Plan says that the requested partial denture is not medically necessary.
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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the service is medically necessary. Our physician reviewer found that due to the missing mandibular teeth bilaterally, replacement with a partial denture to oppose a complete maxillary denture is medically reasonable and necessary, thus meets the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pre-approve a partial lower denture(D5214).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient office visit to be provided by an OON
provider.
You asked the Plan to pre-approve the outpatient office visit. You say that you have been seeing this dentist for
several years and would like to continue receiving services from him. You also say that this provider is close to
your home. The Plan denied your request. The Plan says the requested provider is an out-of-network provider.
The Plan also says that dental services are only covered with providers in the Plan's network.
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. The Plan also found that there is an in-network provider within
5 miles of your home. Therefore, we decided that the Plan does not have to pre-approve an outpatient office
visit to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the provider has known you for years, and
knows your life. The Plan denied your request. The Plan says continuity of care has not been established.
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. The Plan's rules for continuity of care have not
been met. 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 medical services to be provided by an out of network
(OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient hospital services rendered on August 27, 2019 and August 30, 2019.
You asked the Plan to waive the copayments for these services. You say that the enrollee should have a $40 specialist copayment. The Plan denied your request. The Plan says the copayments were 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 $200 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.
Review of the file shows that the enrollee received services in an outpatient hospital facility on August 27, 2019 and August 30, 2019. Per the contract with the Plan, there is a $200 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. However, the Medicare allowed amount for these services was $185.84 per visit. Given that the allowed amount was less than the $200 copayment, the enrollee has been asked to pay $185.84 per visit, for a total of $371.68. Therefore, we decided that the Plan does not have to waive the copayments for the outpatient hospital services rendered on August 27, 2019 and August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3310) and a core buildup,
including any pins when required (D2950).
You asked the Plan to pre-approve the endodontic therapy and core buildup. You say that you cannot afford to
pay for these services with your monthly income. You also say that these services are medically necessary. The
Plan denied your request. The Plan says these services are not covered benefits under your 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. Therefore, we decided that the Plan does not have to pre-approve
endodontic therapy (D3310) and a core buildup, including any pins when required (D2950).