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

We decided that the Plan does not have to pre-approve a standard wheelchair rental.
You asked the Plan to pre-approve a standard wheelchair rental. You say that there is no way to transport the
power wheelchair as you do not have a lift for the car. The Plan denied your request. The Plan says Medicare
rules do not provide coverage for a manual wheelchair and a power wheelchair at the same time.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary. Medicare does not cover back up or secondary wheelchairs.
The file shows that you have a power wheelchair. The power wheelchair serves the same purpose as a standard
wheelchair rental. Therefore, we decided that the Plan does not have to pre-approve a standard wheelchair
rental. If your current power wheelchair is impairing your participation in mobility related activities of daily
living in the home you can contact the Plan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair and replacement parts for a wheelchair (E2601) (K0739). You asked the Plan to pre-approve the repair and replacement parts. You say that there is an exception for wheelchair cushions.The Plan denied your request. The Plan says Medicare does not cover durable medical equipment (DME) in a skilled nursing facility (SNF) based on statutory definition of DME.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 the repair and replacement parts is being requested for use in a SNF or hospital.Therefore, we decided that the Plan does not have to pre-approve repair and replacement parts for a wheelchair (E2601) (K0739).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that your primary care physician (PCP) gave the okay to see this provider.The Plan denied your request. The Plan says the services were rendered by an out-of-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. The file shows that your PCP requested authorization for this provider but the Plan denied authorization. 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 June 4, 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 a Shingles vaccine (90736) provided on October 2, 2019.
You asked the Plan to pay for the Shingles vaccine. You say that you would like reconsideration because this immunization is covered by the Plan and the coding should be changed to pharmacy to accommodate coverage. The Plan denied your request. The Plan says the Medicare Part B plan covers vaccines that are necessary to treat an injury or illness.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for a Shingles vaccine (90736) provided on October 2, 2019.
Benefits for the Shingles vaccine 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 durable medical equipment to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe out of network durable medical equipment. You say that you deliver to the enrollee's home and fit the enrollee at her home.The Plan denied your request. The Plan says the durable medical equipment being requested is available with the provider network.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-approvedurable medical equipment to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroutpatient surgery provided on October 11, 2019.You asked the Plan to waive the coinsurance foroutpatient surgery. You say that your provider asked to be covered in-network since they were the closest specialist. You say that the claim should be processed in-network.The Plan denied your request. The Plan says the coinsurance 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 30% coinsurance for outpatient surgery at an out-of-network hospital.You have been asked to pay $199.48, which is 30% of the allowed amount for the surgery. The allowed amount is $664.94 (30% x $664.94 = $199.48). The surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 foroutpatient surgery provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis.
You asked the Plan to pre-approve a knee orthosis. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that knee orthoses are covered if the enrollee has had recent injury to or a surgical procedure on the knee(s). 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 knee orthosis. Our reviewer says that the requested knee orthosis is not medically reasonable and necessary. Our physician reviewer found that the enrollee presents with chronic left lateral knee pain with associated locking symptoms. Functional limitations are noted in activities of daily living. Clinical exam findings are consistent with radiographic evidence of tricompartmental osteoarthritis with valgus angulation, reported to be bone-on-bone. Ligamentous exam was documented as stable. He had failed conservative treatment, and was recommended for hyaluronic acid injections. Under consideration is a request for left knee orthosis (L1851). There is no evidence that the enrollee had a recent injury or surgery to the knee. There is no documentation of a subjective complaint of instability or knee instability on physical exam. Therefore, the enrollee does not meet Medicare coverage criteria for the requested knee orthosis (L1851).
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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on September 17, 2019.You asked the Plan to waive the copay forthe ambulance transport. You say that this was your only form of transportation option and should not have to pay.The Plan denied your request. The Plan says that the correct copay was 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 $225 copay for each one-way Medicare-covered ground transportation service.You have been askedto pay a $225 copay for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground transportation service 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 forthe ambulance transport provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the facility.
You asked the Plan to pre-approve the physician's services to be provided by the facility. You say that this provider is world class organization with a team of physicians and other staff who are familiar with multiple myeloma. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services to be provided by the facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on October 7, 2019.You asked the Plan to waive the copayment forthe EKG. You say that you should not be responsible for the copayment because you have received the EKG in the past.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 $20 copayment for Medicare-covered non-radiological diagnostic services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the EKG.You have been asked to pay a $16.43 copayment for the EKG. The EKG 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 forthe EKG provided on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) system.You asked the Plan to pre-approvea CGM. You say that the enrollee cannot read the meter and is not aware of low blood sugar.The Plan denied your request. The Plan says the enrollee is not insulin injecting three or more times a day or adjusting the dose based on test results.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 CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dexcom G6 continuous glucose monitor (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete upper denture (D5110) complete lower denture (D5120).You asked the Plan to pre-approve the dentures. You say that before you signed up with the plan you questioned about coverage for dentures. You explained that you needed new ones and wanted to be sure you were covered and you were told that it would be covered.The Plan denied your request. The Plan says the requested service is not a covered benefit due to teeth missing prior to coverage.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 health plan contract on page 110 specifically says that initial installation of a bridge or denture to replace teeth missing prior to coverage is not covered.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 complete upper denture (D5110) complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 PWC and accessory items.
You asked the Plan to pre-approve the PWC and accessories. You say that your current wheelchair is eight years old and the frame is irreparable. The Plan denied your request. The Plan says the documentation does not support the medical necessity of this item.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. The documentation is insufficient to support that your condition cannot be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 PWC and accessory items.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on September 30, 2019.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you cannot afford the copayment and you assumed this procedure was covered. 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 $295 copayment for in-network 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 $295 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 upper GI endoscopy provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound study of arteries provided on October 16, 2019.
You asked the Plan to waive the deductible for an ultrasound study of arteries. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $245 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received an ultrasound study of arteries on October 16, 2019. The record shows that you had paid $0 toward the $245 deductible. Therefore, you are responsible to pay the allowed amount of $234.43. You have been asked to pay the deductible amount of $234.43 for an ultrasound study of arteries. An ultrasound study of arteries 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 deductible for an ultrasound study of arteries provided on October 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bath/shower chair.You asked the Plan to pre-approve a bath/shower chair. You say that the shower chair is necessary due to you suffer from a variety of illness.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair 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 bath/shower chair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a SPECT test provided on August 9, 2019.
You asked the Plan to reduce the copayment for the SPECT test. You say that you do not agree with having to pay the higher copayment for this service because the claim was not processed correctly the first time. The Plan denied your request. The Plan says the claim has been corrected and 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 $350 copayment for each covered nuclear medicine study including PET scans. You have been asked to pay a $350 copayment for the SPECT test. The SPECT test 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 reduce the copayment for the SPECT test provided on August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 30, 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-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 forthe medical services provided on September 30, 2019 to ENROLLEE by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 10,
2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of
the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing
services provided to the enrollee on July 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) and a porcelain crown (D2740).You asked the Plan to pre-approvethe core build up. You say that the enrollee presents with discomfort on tooth # 12. You say that tooth # 12 has severe attrition that the existing filling will not withhold attrition from happening. You also say that for best long term success, core build up and a crown are necessary.The Plan denied your request. The Plan says core build up is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers adental 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 core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) and a porcelain crown (D2740).