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

We decided that the Plan does not have to waive the copayment for an electrocardiogram (ECG) (93000) provided on December 6, 2019 by the provider.You asked the Plan to waive the copayment for the ECG. You say that you should only be responsible for 20% of the allowable charges.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $20copayment for each Medicare-covered x-ray visit and/or simple diagnostic test.You have been asked to pay $17.52 (the allowed amount) for the ECG. An ECG falls within the Medicare-covered x-ray visit and/or simple diagnostic test 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 electrocardiogram (ECG) (93000) provided on December 6, 2019 by the provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine ophthalmological examination including refraction (S0621) provided December 16, 2019.
You asked the Plan to pay for the vision services. You say that you did not know you had coverage so you did not submit your insurance card for consideration. After you received the denial you learned the provider had coded your personal receipt incorrectly. The Plan denied your request. The Plan says this service is not a covered benefit.
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 an eye exam and 1 pair of eyeglasses or contact lenses after each cataract surgery. We looked at the file and the Plan's rules. this service is not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan
does not have to pay for routine ophthalmological examination including refraction (S0621) provided December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visits, x-rays, ankle strapping and ultrasound therapy provided on July 15, 2016, July 26, 2016 and August 11, 2016.You asked the Plan to waive the copayment forthe office visits, x-rays, ankle strapping and ultrasound therapy. You say that you paid the balance at the time of service. You say that you should have no balance due.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate termsall cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each Medicare-covered visit for in-network podiatry services, a$40 copayment for each in-network, Medicare-covered physical therapy and speech-language therapy visit and a$16 copayment for each in-network, Medicare-covered standard x-ray service.  You have been asked to pay a total of $158.60for the office visits, x-rays, ankle strapping and ultrasound therapy. Date of ServiceServiceAllowed AmountStandard CopaymentMember LiabilityJuly 15, 2016Office Visit$74.27$50$50July 15, 2016X-Ray$19.62$16$16July 26, 2016Office Visit & Ankle Strapping$67.53$50$50July 26, 2016X-Ray$19.62$16$16August 11, 2016Ankle Strapping$17.95$50$17.95August 11, 2016Ultrasound Therapy$8.65$40$8.65TOTAL:$158.60The office visitsand ankle strappingfallwithin the "Podiatry Services" benefit category. The x-rays fall within the "Outpatient Diagnostic Tests andTherapeutic Services and Supplies" benefit category. The ultrasound therapy falls within the "Outpatient Rehabilitation Services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the office visits, x-rays, ankle strapping and ultrasound therapy provided on July 15, 2016, July 26, 2016 and August 11, 2016.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight manual wheelchair.
You asked the Plan to pre-approve a lightweight manual wheelchair. You say that you need a wheelchair to
shop and go around the block for fresh air. The Plan denied your request. The Plan says the documentation
supplies does not support medical necessity.
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair will not be covered if the
patient does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can
be ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the
manual wheelchair.
The file does not show you do have a mobility deficit that impairs your participation in MRADLs, your
condition cannot be improved by a walker or cane, or you can safely propel the wheelchair being requested.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers wheelchairs for use only outside the home. Therefore, we decided that the Plan
does not have to pre-approve a lightweight manual wheelchair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that no authorization is needed when performed at home. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
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 plan that the member is enrolled in has a network lock-in feature. 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 x-ray provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora stool analysis for blood provided on December 13, 2019.You asked the Plan to waive the copayment fora stool analysis for blood. 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 $35 copayment for labs. You have been asked to pay the allowed amount of $17.67, which isless than the $35 copayment for a stool analysis for blood. A stool analysis for blood 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 basedon 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 fora stool analysis for blood provided on December13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve life alert, medical alarm system.
You asked the Plan to pre-approve life alert, medical alarm system. You say that you feel very alone because your husband is in a nursing home and is burdened with the weight of that. You are frightened and hardly ask for assistance and is feeling very neglected. The Plan denied your request. The Plan says the requested service is not covered.
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 life alert, medical alarm system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea DexcomG6 Continuous Glucose Monitoring System.You asked the Plan to pre-approvea continuous glucose monitor. You say that you need a CGM because you have been hospitalized for hypoglycemia.The Plan denied your request. The Plan says you are not diabetic.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea Dexcom G6 Continuous Glucose Monitoring System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral liquid nutrition and oral swabs.
You asked the Plan to pre-approve oral liquid nutrition and oral swabs. You say that the enrollee needs these
items. The Plan denied your request. The Plan says enteral nutrition for oral intake and disposable oral swabs
are not covered by Medicare or the Plan
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
Medicare rules say that enteral nutrition products administered orally are not covered. Medicare does not cover
disposable items.
The items you asked the Plan to pre-approve are nutritional supplements and disposable items. Therefore, we
decided that the Plan does not have to pre-approve oral liquid nutrition and oral swabs.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide Group 3 standard power wheelchair upgraded electronics.You asked the Plan to provide the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs the power wheelchair, accessories and electronic upgrades.The Plan denied your request. The Plan says the electronic upgrades cannot be covered as it is not medically necessary to control the three approved power options through the joystick.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. Documentation shows that the enrollee has normal range of motion and 3/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. This means that Medicare rules for coverage of upgraded electronic shave not been met.Therefore, we decided that the Plan does not have to provide Group 3 standard power wheelchair upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.You asked the Planto pre-approvea continuous glucose monitor. You say that your fingers are numb from finger stick testing and you are afraid of infection.The Plan denied your request. The Plan says the records show you are not insulin-treated.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. You are not insulin treated by injection or pump. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mechanical traction therapy.
You asked the Plan to pre-approve traction therapy. The Plan denied your request. The Plan says there is no added benefit for additional chiropractic services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Services other than manual manipulation of the spine, when provided by a chiropractor, are not covered. Therefore, we decided that the Plan does not have to pre-approve mechanical traction therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift.You asked the Plan to pre-approvea seat lift. You say that getting out of your recliner causes you pain.The Plan denied your request. The Plan says that you do not meet criteria for coverage.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. The file includes a certificate of medical necessity signed by your provider which indicates you are not completely incapable of standing up from a regular chair or any other chair in your home. Based on this information, we decided that Medicare rules for coverage of a seat lift have not been met.Therefore, we decided that the Plan does not have to pre-approveaseat lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 8, gingival irrigation (D4921 x 5), an adjunctive pre-diagnostic test (D0431), topical application of fluoride varnish (D1206), and core build up (D2950 x 2).You asked the Plan to pre-approve the dental services. You say that due to the enrollee's health issues, he is more susceptible to more health issues. You say that you would like the additional dental care done to prevent illness. You say that you cannot afford to pay for the enrollee's problems that will not be covered.The Plan denied your request. The Plan says 2 crowns are covered per calendar year. The Plan says that 2 crowns were approved in February 2020 and therefore the frequency limit has been exhausted. The Plan also says that gingival irrigation, adjunctive pre-diagnostic testing, topical application of fluoride varnish, and core build up are not listed as covered services.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 crowns are a covered service, the frequency limit of 2 crowns per calendar year has been exhausted. The record shows that the Plan approved 2 crowns in February 2020. Additionally, the requested gingival irrigation, adjunctive pre-diagnostic testing, topical application of fluoride varnish, and core build up are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 8, gingival irrigation (D4921 x 5), an adjunctive pre-diagnostic test (D0431), topical application of fluoride varnish (D1206), and core build up (D2950 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, and prophylaxis provided by an OON provider on July 31, 2019.
You asked the Plan to pay for the periodic oral evaluation, intraoral periapical x-rays, and prophylaxis. The Plan denied your request. The Plan says you are non-participating with the enrollee's plan. The Plan also says that you, as well as the enrollee, are responsible for verifying eligibility prior to the services being rendered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, and prophylaxis provided by an OON provider on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electro-acupuncture device (L8679). You asked the Plan to pre-approve the electro-acupuncture device. You say that this is not an electro-acupuncture Device. The Primary Relieve VI is a percutaneous nerve stimulator, a medical device and differs from electro-acupuncture devices for many reasons. The Plan denied your request. The Plan says the requested item is not covered. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electro-acupuncture device have not been met. Therefore, we decided that the Plan does not have to pre-approve the electro-acupuncture device (L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network benefit exception for consultations with an out-of-network provider.
You asked the Plan to pre-approve the in-network benefit exception. You say that you would like reconsideration because you are not able to choose which provider you see. The Plan denied your request. The Plan says there are in-network providers available for consultation so if you elect to use an out-of-network provider, your cost sharing will be higher.
The Plan must follow Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the in-network benefit exception have not been met. Specifically, the record indicates that there are in-network providers available. Therefore, we decided that the Plan does not have to pre-approve an in-network benefit exception for consultations with an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesurgical mask, per 20 (A4928).You asked the Planto pre-approvethe surgical mask. You say that you have regular doctor's appointments and  You are taking care of a child and want to prevent infection from Covid-19.The Plan denied your request. The Plan says this service is not covered.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-approvesurgical mask, per 20 (A4928).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve otolaryngology services to be provided by an out of network (OON) provider. You asked the Plan to pre-approve the OON services. You say that the plan doesn't have the equipment for the procedure you want. The Plan denied your request. The Plan says the service is available within the 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 OON services. Therefore, we decided that the Plan does not have to pre-approve otolaryngology services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 2, 2019.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 are not covered.The Plan must follow Medicare rules. Medicare rules say that codes with a PC/TC indicator of 8 will pay the PC only when billed for hospital inpatient.We looked at the file and Medicare rules. The provider billed code 85060 with a place of service code 22 for outpatient hospital. This code has a PC/TC indicator of 8, and the PC is only covered when billed in an inpatient hospital setting. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 2, 2019.