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

We decided that the Plan does not have to pre-approve a shower chair.You asked the Plan to pre-approve a shower chair. You say that you need a shower chair because you can't be standing in the shower for a long time and you have fallen.The Plan denied your request. The Plan says this item 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 shower chair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 12, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you were only given an ibuprofen and an x-ray. 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 $120 copayment for emergency services at an in-network emergency room. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe emergency room visit provided on October 12, 2019. Your complaint about the provider not looking at your hand is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services performed on August 20,
2019.
You asked the Plan to waive the copayment for specialist services. You say that this was your yearly routine
eye exam. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019
EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
A refraction exam was also billed on the claim. That was denied as a non-covered service. Refraction exams
are excluded from coverage by Original Medicare rules. The provider's office had written that charge off and
you owe nothing for the refraction exam. However, you received specialist office services and you are asked to
pay a $45 copayment for the services. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for specialist services
performed on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from August 28, 2019 through October 28, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received portable oxygen contents from August 28, 2019 through October 28, 2019. You have been asked to pay 20% coinsurance each month of the allowed amount for the DME. The allowed amount is $66.38. The total you owe each month is $13.28 ($66.38 x 20% = $13.28). Therefore, you are being billed for the DME for three (3) months and your total is $39.84 ($13.28 x 3 months = $39.84). 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 forportable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from August 28, 2019 through October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on October 7, 2019.You asked the Plan to waive the copayment for an ECG. You say that you disagree with the charges because you have never been charged in the past.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 $5 copayment for diagnostic procedures.The medical records show that you received an ECG on October 7, 2019. Therefore, you are responsible to pay the $5 copayment.  You have been asked to pay a $5 copayment for an ECG. An ECG 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 foran ECG provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 10, 2019.You asked the Plan to waive the copayment for the office visit. You say that there is no copayment for an obesity screening. You say that the copayment should be removed.The Plandenied 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 Planclearly says that you must pay a $45 copayment for provider and professional services at an in-network specialist's office.You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was with a specialist. 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 office visit provided on October 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physical therapy services provided on February 19, 2019 to June 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physical therapy services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 physical therapy services provided on February 19, 2019 to June 25, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visit provided on October 24, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that they did not do anythingfor you. You say that you don't think you need to pay.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 $120 copayment for emergency care.You have been asked to pay $115.76, which is less than the standard $120 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were examined and given medication during the ED visit. 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 ED visit provided on October 24, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 9, 2019.You asked the Plan to pay for the physician's services. 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 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe bitewing x-rays (D0274) provided on September 5, 2019.You asked the Plan to pay the in network rate forthe bitewing x-rays. You say that the services should be processed as in network. You say that 3 dentists at Access Dental were listed as innetwork providers. You say that the office assured you they were in network. You also say that you exercised due diligent care to be seen by an in network provider.The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per calendar year. The Plan also says that the frequency limit has been exceeded.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 and bitewings are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for bitewing x-rays that you received on February 28, 2019.Therefore, we decided that the Plan does not have to pay the in network rate forthe bitewing x-rays (D0274) provided on September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 31, 2019.You asked the Plan to pay forthe orthosis. You say that the documentation supports medical necessity.The Plan denied your request. The Plan says the record does not support do not show any injury, instability, ligamental laxity or deformity.The Plan follows Medicare rules. Medicare rules say that to meet coverage criteria there must be documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and/orobjective documentation of joint laxity. 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 orthosis. Our reviewer says that the supplies are not medically necessary. Our physician reviewer found that the enrollee has chronic left knee pain. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is no objective documentation of joint laxity.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 orthosis have not been met.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with physicians at the hospital. You asked the Plan to pre-approve the consultation. 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 caseis 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 a consultationwith physicians at the hospital.
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 doctor". You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, 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 doctor".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and the fillings (D2332) for teeth # 8 and 9 provided from October 16, 2019 to October 29, 2019.
You asked the Plan to pay for the dental services. You say that you moved from Wisconsin to Arizona on December 5, 2019. You say that the Arizona dental coverage is more comprehensive than the Wisconsin coverage and you believe that previous claims should be covered. You also say that besides the letter you received on October 31, 2019 in regards to a letter you sent on December 12, 2018 you had received no other correspondence. The Plan denied your request. The Plan says the frequency limit for cleanings has been exceeded. The Plan also says that fillings are not a covered service.
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 and cleanings are a covered service, the frequency limit of once per calendar year has been exceeded. Additionally, fillings are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and the fillings (D2332) for teeth # 8 and 9 provided from October 16, 2019 to October 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided on May 22, 2019.You asked the Plan to waive the coinsurance for outpatient surgery. You say that you were charged for being out-of-network. You say that you were not informed the surgical facility should be 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 20% coinsurance for out-of-network surgery services.You have been asked to pay a total of $945.56 for outpatient surgery. Outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the provider is out-of-network. 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 May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to approve continued rental of the Group 2 power wheelchair and accessories.You asked the Plan to approve continued rental of a Group 2 power wheelchair and accessories. You say that because of medical conditions the enrollee continues to need the PMD.The Plan denied your request. The Plan says the documentation submitted states the enrollee is with normal gait and with full range of motion.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 does not show that the enrollee has a mobility deficit that impairs their participation in MRADLs, their condition cannot be improved by a walker, cane or manual wheelchair, orthat they can safely operate the PMD being requested.The Seating/Mobility Evaluationis not current. There is no home assessment documentation. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to approve continued rental of the Group 2 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay forthe one periodic oral evaluation. We decided that the Plan does not have to pay forthe intraoral periapical x-rays and bitewings. You asked the Plan to pay forthe one periodic oral evaluation, intraoral periapical x-rays, and bitewings. You say that the provider should be responsible for the payment because you did not make an appointment to have x-rays and dental exams. You also say that you thought you were going to the dentist for partial denture adjustments.The Plan says that the benefits provided for the periodic oral evaluation include all related services and are based on the maximum fee allowable by the Plan. The Plan also says that the benefits for the intraoral periapical x-rays and bitewing x-rays had been satisfied and the frequency limitation had been exceeded.  We decided that the Planhas to pay forthe one periodic oral evaluation. The Plan contract says that exams (periodic oral exam (code D0120), limited oral evaluation -problem focused (code D0140) and comprehensive oral evaluation (code D0150)) are limited to two procedures per calendar year. Office visit for observation (code D9430) provided on June 7, 2019 is not included on this list and consequently does not count against the frequency limitation for exams.Therefore, we decided that the Plan has to pay forthe one periodic oralevaluation. We also decided that the Plandoes not have to pay forthe intraoral periapical x-rays and bitewings.Though the Plan offers a dental benefit in excess of Medicare coverage, bitewings and intraoral x-rays are each limited to one set per calendar year. The record shows that you received a bitewing x-ray and an intraoral x-ray on June 7, 2019 and your bitewing x-rays and intraoral x-rays benefits were then exhausted.Therefore, we decided that the Plan does not have to pay forthe intraoral periapical x-rays and bitewings.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.Your complaint about not receiving the services you thought you would get is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine hearing services provided on September3, 2019, by an out-of-network provider.You asked the Plan to pay for the routine hearing services. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says you do not have out-of-network benefits.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the routine hearing services have not been met. The provider is not in-network and your EOC clearly states, routine hearing services must be received from a participating provider in order to be covered by the plan.Therefore, we decided that the Plan does not have to pay for the routine hearing services provided on September 3, 2019, by an out-of-network provider.