Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy. 
 
You asked the Plan to pre-approve massage therapy. You say that the massage can be done with physical 
therapy and there is no need for outside intervention. You say that this will help with your extreme pain and is 
a reasonable request. The Plan denied your request. The Plan says services provided by a massage therapist are 
not covered. 

The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Massage 
therapy is only covered as part of physical therapy program in accord with Medicare guidelines. Contact the 
Plan regarding massage therapy being provided by your physical therapist. Therefore, we decided that the Plan 
does not have to pre-approve the massage therapy provided a massage therapist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in tub.
You asked the Plan to pre-approve the tub. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered a comfort or convenience item.
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 a walk-in tub.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this item still does not meet the coverage criteria. 
 
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 a power seat elevation system (E2300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services you received on May 13, 2021.

You asked the Plan to waive the copayment for the PT services. You say that you were not informed of any cost sharing for these services. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for physical therapy services. 

You have been asked to pay a $40 copayment for the PT 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 the physical therapy (PT) services you received on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PureWick external female catheter and replacement catheters.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not considered a prosthetic device and 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 a PureWick external female catheter and replacement catheters.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up office visit to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a follow-up office visit to be rendered by the out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from
January 15, 2020, to January 18, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the
charges because you needed an aortic valve replacement. 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 $290
copayment for days 1-6 for inpatient hospital care.

You had an inpatient hospital stay from January 15, 2020, to January 18, 2020. Therefore, you are responsible
to pay a $290 copayment for days 1-3 (January 15, 2020, to January 17, 2020). The total amount you owe is:
$290 (copayment) x 3 (inpatient days) = $870.

You have been asked to pay the total copayment amount of $870 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital 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 for an inpatient hospital stay provided from January 15, 2020, to January 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist office visit and the routine venipuncture 
provided on May 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the specialist office visit and the routine venipuncture. You say that the current 
procedure terminology (CPT) codes are supported with documentation. The Plan denied your request. The Plan 
says 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the specialist office visit and the routine venipuncture provided 
on May 14, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on August 26, 2020.

You asked the Plan to pay for the lab services. You say that it is crucial to monitor those receiving treatment for pain management or substance abuse. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that the claim lists the place of service as an independent laboratory. The records provided do not indicate the specimen was obtained at the independent laboratory at issue in this case. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic appliance provided on November 12, 2020.

You asked the Plan to pay for the provided item. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code E0673 is Intermittent limb compression device (includes all accessories), not otherwise specified. 

We find that CPT code E0673 is not supported in the medical record. Specifically, the records provided do not indicate the device was used for a covered indication. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. Based on this information, we decided that Medicare rules for coverage of the provided item have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic appliance provided on November 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on June 25, 2021.

You asked the Plan to waive the copayment for the medical eye exam. You say that you just had a routine eye exam, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for medical eye exams. 

You have been asked to pay a $35 copayment for the medical eye exam. The medical records from this visit show that in addition to routine services, you were also evaluated to squamous blepharitis of both lower eyelids and were provided instruction to care for this condition. This is not part of a routine exam and is a medical evaluation. That is why the eye exam you had falls within the medical eye exams 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 medical eye exam you had on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a general health panel provided to the enrollee on February 4, 2021.
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for a general health panel provided to the enrollee on February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you need these shoes because your left foot will always be a different size due to the surgery and swelling you have since your operation. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture and lower partial denture. 
 
You asked the Plan to pre-approve the complete upper denture and lower partial denture. You say that the 
denture is broken, and you cannot eat. You say that you are a cancer patient, and you need to eat. The Plan 
denied your request. The Plan says the services exceed the benefit allowance. 
 
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, you also have a maximum benefit of 
one complete and partial denture per arch every 60 months. The Plan paid for the complete upper denture and 
lower partial denture provided on June 4, 2018, which exhausted your benefit. Therefore, we decided that the 
Plan does not have to pre-approve the complete upper denture and lower partial denture.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) 
procedure you had at an ambulatory surgical center on May 27, 2021. 
 
You asked the Plan to waive the copayment for the EGD procedure. You say that you would have never had 
this procedure had you known it would cost this much. The Plan denied your request. The Plan says you were 
charged this copayment 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 $500 
copayment for outpatient surgery and services at an ambulatory surgical center.  
 
You have been asked to pay a $500 copayment for the EGD procedure. The EGD procedure falls within the 
outpatient surgery and services at an ambulatory surgical center 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 esophagogastroduodenoscopy (EGD) procedure you had 
at an ambulatory surgical center on May 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services provided on April 28, 2021.

You asked the Plan to pay for the services provided. You say that the nursing visit notes were provided for review. The Plan denied your request. The Plan says the rules for payment have not been met.

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 99601 and 99602 are not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services provided on April 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested drug have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Aranesp. Our reviewer says that the requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that, based on the medical records provided and the Medicare-approved major drug compendia, there is no documentation that supports that the Aranesp meets Medicare criteria as medically reasonable and necessary for the enrollee. Records do not document the enrollee has adequate iron stores or that a diagnosis of iron-deficiency anemia has been excluded. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Aranesp (J0881).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil, 5 mg tablets. 
 
You asked the Plan to pre-approve Tadalafil, 5 mg tablets. You say that your doctor prescribed a daily 5mg 
dose of Tadalafil to treat benign prostatic hyperplasia (BPH). You say that this drug is only approved for 
treatment of BPH, and you have enclosed medical records from the urologist. The Plan denied your request. 
The Plan says this drug is not covered by your Part B plan. 
 
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 Tadalafil, 5 mg tablets.  

Benefits for Tadalafil, 5 mg tablets 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from April 13, 2021, to May 13, 2021.

You asked the Plan to waive the copayment for a SNF stay. You say that you are unhappy with the quality of care you received and should not be responsible for 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 $0 copayment for days 1-20 and a $180 copayment for days 21-100 for SNF care. 

You had a SNF stay from April 13, 2021, to May 13, 2021. You are not being charged a copayment for days 1-20 (April 13, 2021, through May 2, 2021). You are responsible to pay a $180 copayment for days 21-30 (May 3, 2021, to May 12, 2021). The total amount you owe is: $180 (copayment) x 10 (SNF days) = $1,800. 

You have been asked to pay the total copayment amount of $1,800 for a SNF stay. A SNF stay falls within the SNF 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 for a SNF stay provided from April 13, 2021, to May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cytopathology services you received on March 24, 2021.
You asked the Plan to waive the copayment for the cytopathology services. You say that you feel as though you were wrongly billed for lab work. You feel as though the fee is excessive. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan stated that you are only responsible for the $15 copayment for the lab services.
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 $15 copayment for lab services. You have been asked to pay a $15 copayment for the cytopathology services. The cytopathology services fall within the lab 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 cytopathology services you received on March 24, 2021.