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

We decided that the Plan does not have to waive the copayment forthe laryngoscopy provided on November 5, 2019.You asked the Plan to waive the copayment forthe laryngoscopy. You say that when you have an appointment with the throat doctor you have a $35 copayment. You say you have been charged an additional $100 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 inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $100 copayment for the laryngoscopy. The laryngoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you were billed by the outpatient hospital.This means that you have been asked to pay the correct amount based onyour 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 laryngoscopy provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to enrollee on October 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say thatthe PC and TC for diagnostic services are separately payable only when furnished in different payment localities.We looked at the file and Medicare rules. The file shows that the PC and TC for the laboratory services were not performed in separate payment localities and therefore are not separately payable.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered to enrollee on October 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.You asked the Plan to pre-approve the compression stockings. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for these items is correct, because these compression stockings are not covered by Medicare.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the requested services have been found to be not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the medical records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. The enrollee's needs do not require the professional skills of a skilled nurse. She has no IV medications, complex wound care, new enteral feedings or tracheostomy tube. Her conditions and needs do not require 18 skilled care visits. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the SNF stay provided from October 1, 2018 through October 31, 2018.
You asked the Plan to waive the coinsurance for the SNF stay. You say that you were only there to get antibiotics 4 times a day. You say that you should get a discount. 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 each out-of-network Medicare-covered SNF stay, up to 100 days. You have been asked to pay $3,800.49, which is 30% of the allowed amount for the SNF stay. The allowed amount is $12,668.31 (30% x $12,668.31 = $3,800.49). The SNF stay falls within the "Skilled Nursing Facility (SNF) Care" 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 for the SNF stay provided from October 1, 2018 through October 31, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for enrollee .You asked the Plan to pre-approve a power wheelchair. You say that the enrollee has increasing problems with balance.The Plan denied your request. The Plan says the enrollee's needs can be met with a lesser device, such as a quad cane.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. 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 power wheelchair. Our physician reviewer found that the enrollee has a history of falls and has chronic pain including bilateral foot and ankle pain. The enrollee currently uses a single-point cane, and has access to a walker with a seat. She does not have upper extremity impairment that would limit her ability to use an assistive device or propel a manual wheelchair. The information provided does not confirm that the enrollee's mobility related activities of daily living cannot be met through the use of standard mobility aides.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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitoring (CGM) system and supplies as identified by CPT Codes A9276 and A9278.You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says Medicare only covers the requested items when using certain code numbers.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes A9276 and A9278 are not used to bill for continuous glucose monitoring items.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitoring (CGM) system and supplies as identified by CPT Codes A9276 and A9278.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic mammography (77065) provided on March 2, 2018 
You asked the Plan to pay for the diagnostic mammography. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says the claim was not received within the 365 day timely filing period.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the diagnostic mammography was not filed until April 23, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for a diagnostic mammography (77065) provided on March 2, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle.You asked the Plan to pre-approvea scooter. You say that you cannot get to your physician's office for a face-to-face.The Plan denied your request. The Plan says there is no physician face-to-face documentation.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 therequested PMD. The file does not showthat you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair,or  you can safely operate the PMD being requested. 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-approvea power operated vehicle.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 14, 2019.
You asked the Plan to pay for the drug test. 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
drug test. 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 a drug test provided on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for monthly oxygen provided from August 27,2019 through November 27, 2019.You asked the Plan to waive the coinsurance forthe 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 monthly oxygen provided from August 27, 2019 through November 27, 2019. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount per month is $66.38. The total you owe per month is $13.28 ($66.38 x 20% = $13.28). You received oxygen for four (4) months. The total you owe for the oxygen is $53.12 ($13.28 x 4 months = $53.12). 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 formonthly oxygen provided from August 27, 2019 through November 27, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).You asked the Plan to pre-approve the dental item. You say that you previously had partial dentures in 2017. You say also say that you need a new denture on top.The Plan denied your request. The Plan says 1 denture every 60 months is covered. The Plan also says that the frequency limit for dentures has been reached.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 dentures are a covered service, the frequency limit has been reached. The record shows that the Plan paid for dentures that you last received on June 28, 2017, less than 60 months ago.Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies for enrollee.You asked the Plan to pre-approve incontinence supplies. You say that the enrollee cannot get around without the supplies.The Plan denied your request. The Plan says the requested items are not covered.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies for enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the diazepam and oxycodone-acetaminophen provided on November 23, 2019.You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these drugs are not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs.The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe diazepam and oxycodone-acetaminophen provided on November 23, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forgym membership purchased on November 15, 2018.You asked the Plan to pay forgym membership renewal. You say that your longstanding health membership is annual and does not coincide with the calendar year. Your gym membership required renewal in mid-November 2018 for the following year, 2019.The Plandenied your request. The Plan says the enrollee's coverage was not in effect on the date services were purchased.The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits.Therefore, we decided that the Plan does not have to pay forgym membership purchased on November 15, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 16, 2019 to December 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that the provider's office assured you that they accepted your insurance.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 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 forthemedical services provided on December 16, 2019 to December 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora hospital physician evaluation provided on October 16, 2019.You asked the Plan to pay for physician evaluation. You say that this provider is credentialed and is allowed to bill for this service.The Plan denied your request. The Plansays that the denial of payment for this service is correct, because the Plan does not allow this service to be performed by an Audiologist.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligentefforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide any evidence to support that this service was performed by an Audiologist. The rendering physician. Without this information, the Plan has not shown that its decision to deny payment for this claim is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay fora hospital physician evaluation provided  on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 10 additional extractions (D7140) provided on September 16, 2019 by the out of network provider.
You asked the Plan to pay for 10 additional extractions. You say that you explained to the plan representative the dental services that you needed to get. You say that the plan representative said this plan would cover the services. You also say that the dentures should be covered. The Plan denied your request. The Plan says 2 extractions per calendar year are covered. 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 extractions are a covered service, the frequency limit of 2 per calendar year has been exceeded. The record shows that the Plan paid for 2 extractions that you received on September 16, 2019. Therefore, we decided that the Plan does not have to pay for the 10 additional extractions (D7140) provided on September 16, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental items. You say that you have a lot of medical issues. You say that you lost your dentures 2 weeks ago. You say that you have not been able to eat or chew. You also say that you have lost so much energy and strength as a result. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 dentures are a covered service, the frequency limit of once every 5 years has been reached. The record shows that the Plan paid for the dentures that you received on June 5, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tdap vaccine (70715 and 90471) provided on October 22, 2019.
You asked the Plan to pay for the Tdap vaccine. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Tdap is only covered under Medicare Part B when it is administered for an injury.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap 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 Tdap vaccine. Therefore, we decided that the Plan does not have to pay for a Tdap vaccine (70715 and 90471) provided on October 22, 2019.
Benefits for the Tdap 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sprycel 100mg tablet.
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your request. The Plan says Sprycel is intended for patient self-administration, which means that it is not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sprycel 100mg tablet.