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

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you have been suffering for years with this physical problem. You are in diapers and use 4-6 a day which causes a severe financial hardship and this is an expense you cannot afford. The Plan denied your request. The Plan says this item is not a covered benefit.
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided to the enrollee on December 3, 2019.
You asked the Plan to pay for the supplies. You say that the Plan should reconsider payment. The Plan denied your request. The Plan says if the enrollee is being treated with or without insulin injections, the KX or KS modifier must be added to the code for the monitor, and each related supply, on every claim submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Blood glucose supplies must be billed with modifier KX if the enrollee is being treated with insulin, and modifier KS if the enrollee is not being treated with insulin. We find that HCPCS code K0553 is not supported in the medical record. Specifically, this code requires either modifier KX or KS. The only modifier found on the claim is NU. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for continuous glucose monitor supplies (K0553) provided to the enrollee on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Computed Tomography (CT) scan provided on August 7, 2019.
You asked the Plan to waive the coinsurance for CT scan. You say that when you switched to this Plan you were advised that surgeries, doctor's visits, and specialists would have no out-of-pocket costs for you. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 CT scan. The allowed amount of the claim is $319.55, resulting in a coinsurance obligation of $63.91. You have been asked to pay 20% coinsurance for CT scan. CT scan 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 coinsurance for a Computed Tomography (CT) scan provided on August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 28,
2019 through November 1, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not think you
should be responsible for paying the inpatient hospital copay three (3) times because every time you were
admitted for the same condition. 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).
After a clinical review of the medical records, it was determined that you were admitted as inpatient to on October 25, 2019. You were then transferred later that day (October 28, 2019) for a higher level of care to have a cardiac catheterization with stent placement. This service was not available. On October 29, 2019, you were discharged from  and came back to Emergency Department later that day with shortness of breath. You were
then admitted as an inpatient. Your shortness of breath was related to an adverse reaction from a new
medication that was started when you were inpatient on October 28, 2019. The hospital has
decided to remove the $275 copayment regarding the date of service October 28, 2019.
You were transferred for a higher level of care, which is no fault of the member. This
copayment will be removed and has also decided to remove the $8.52 copayment for the date of service
October 28, 2019 and has also removed the $1.48 copayment for the date of service
October 28, 2019.
According to Chapter 4, page 83 of your EOC, physician services are included with your inpatient hospital
stay. The claims for date of service October 28, 2019 through October 29, 2019 and date
of service October 30, 2019 through November 1, 2019  processed correctly. You are
responsible for the two $275 copayments, totaling, $550. 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 inpatient hospital care from October 28, 2019 through November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that there is no other doctor around you that
can provide these services. The Plan denied your request. The Plan says there is an in-network provider available 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 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
a specialist office visit to be provided by an out of network (OON) provider.
Sincerely,
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Xiidra 5% eye drop medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial as the patient has found some relief from blurred vision and irritation when using this eye drop medication. The Plan denied your request. The Plan says the member has a medical (MA) only policy with the Plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Xiidra 5% eye drop medication.
Benefits for this medication 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214), and psychotherapy (90838) provided
on August 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit, and psychotherapy. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the
member's insurance. You would like the denial for payment reconsidered. The Plan denied your request. The
Plan says the Dr. is a non-network provider who does not work with the member's health plan, and
the member self-directed for services. No prior authorization for any services was noted. The member's primary
care physician did not refer for services. The health plan requires utilization of network providers when
possible and available and requires authorization for certain services. No medical necessity for an out-of-network
provider, such as an urgent or emergency situation, had been documented.
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 for an office visit (99214), and psychotherapy (90838)
provided on August 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the step stool (E1399).
You asked the Plan to pre-approve the step stool. You say that you are in need of this step stool because it is
very helpful to you going in and out of the shower so you don't have to bend your knees too much because they
currently are bone on bone. The Plan denied your request. The Plan says this is a convenience item and is not
covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
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. Therefore, we
decided that the Plan does not have to pre-approve the step stool (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.
You asked the Plan to pre-approve continued physical therapy services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition is not improving.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 continued physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee should have already had adequate instruction in a home exercise program. There are home exercises that are available and effective that do not require any specialized equipment. Ongoing skilled therapy services are not medically necessary. At this point, either the member would be expected to have achieved his goals or they would have been modified to reflect achievable and realistic goals within a reasonable time frame. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) you received on July 3, 2019.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says the services performed are not covered by your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the 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 vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) you received on July 3, 2019.
Benefits for the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that high complexity toxicology testing can be used to assess risk and minimize the high cost of adverse outcomes. The Plan denied your request. The Plan says care is available within 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 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 lab services provided on September 25, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on November 21, 2019.
You asked the Plan to waive the copayment for specialist visit. You say that you do not agree with this copayment amount. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $50 copayment for specialist visit. The enrollee has been asked to pay $50 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens upgrade, progressive lenses (V2781) for eyeglasses purchased September 20, 2019.
You asked the Plan to pay for the lens upgrade. You say that your policy says that you are eligible for 1 free pair of eyeglasses after cataract surgery and you feel this should be paid. The Plan denied your request. The Plan says upgrades on lenses are not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when Covered eyeglasses after cataract surgery includes standard frames and lenses; any upgrades are not covered. We looked at the file and the Plan's rules. upgrades on lenses are not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the lens upgrade have not been met. Therefore, we decided that the Plan does not have to pay for the lens upgrade, progressive lenses (V2781) for
eyeglasses purchased September 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain
management infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (S9328) provided to the enrollee from November 25, 2019 to December 2,
2019.
You asked the Plan to pay for these services. You say that this should be covered as it is a valid procedure code
according to Medicare. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered
as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare.
The plan does not include a mandatory supplemental benefit for home infusion therapy services or
supplies.
You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan
does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay
for the home infusion therapy, implanted pump pain management infusion; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided
to the enrollee from November 25, 2019 to December 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 2, 2019 to April 22, 2019.
You asked the Plan to pay for the services. You say that these services were medically necessary. The Plan denied your request. The Plan says the services were received from providers who are not under contract with the health plan and are not certified with Medicare.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. The two rendering providers are not eligible to bill Medicare. The plan did not pre-approve the services. 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 March 2, 2019 to April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there are in-network providers available for the service in question. 
 
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 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. 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 the medical services to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-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 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 medical services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the varicose vein treatment to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the varicose vein treatment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 the varicose vein treatment 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 pay for the medical services provided on July 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the enrollee did not inform you about his insurance change. The Plan denied your request. The Plan says the services were not authorized.
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 on July 23, 2019 by an out of network (OON) provider.