Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for Affinity skin substitute material and skin graft services provided on June 4, 2021 and June 25, 2021.
You asked the Plan to waive the cost-sharing for skin substitute materials and podiatry services. You say that you cannot afford these charges all at once. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 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 Affinity skin substitute and $35 copayment for podiatry services. The allowed amounts of the
skin substitute supplies total $9,022.72, resulting in a coinsurance amount of $1,804.54. There were 2 covered podiatry visits, resulting in a copayment amount of $70. Your total cost-sharing amount is therefore $1,874.54. You have been asked to pay 20% coinsurance for Affinity skin substitute and $35 copayment for podiatry services. Skin substitute materials and podiatry services fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Podiatry Services" benefit categories. 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 cost-sharing for Affinity skin substitute material and skin graft services provided on June 4, 2021 and June 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided on September 14, 2021.  You asked the Plan to waive the coinsurance for ostomy supplies. You say that this should be covered in full by the Plan. 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 ostomy supplies. The allowed amount of this claim is $370, resulting in a coinsurance amount of $74.  You have been asked to pay 20% coinsurance for ostomy supplies. Ostomy supplies fall within the Prosthetic Devices and Related 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 ostomy supplies provided on September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and pelvis (74176) provided on March 19, 2021.  You asked the Plan to pay for the CT scan services. You say that this claim denied in error. The Plan denied your request. The Plan says this is a duplicate of a claim that has already processed.  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 74176 is computed tomography, abdomen and pelvis; without contrast material.  We find that CPT code 74176 is not supported in the medical record. Specifically, the record indicates that this claim has already processed for payment. The medical records do not indicate that more than one of these services were performed. Therefore, this claim appears to be a duplicate not eligible for further payment. Based on this information, we decided that Medicare rules for coverage of the CT scan services have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and pelvis (74176) provided on March 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography scan (71250) provided on July 28, 2021.  You asked the Plan to pay for code 71250. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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, we have confirmed that code 71250 is a column II code to column I code 71275. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography scan (71250) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that you are concerned that you may be injured while bathing. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on July 12, 2021.
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says the services were received outside the Plan's network with no referral from the member's primary care physician.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a network optical provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's
network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on
July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing facility (SNF) stay provided from July 1, 2021, to July 24, 2021.
You asked the Plan to waive the copayment for SNF stay. You say that you did not stay past 20 days in the facility. 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). Your contract with the Plan clearly says that you must pay $0 copayment per day for days 1 to 20 and $184 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. There were 16 days applied to this SNF benefit period in June 2021. This SNF stay lasted 23 days, which are days 17 to 39 of the benefit period, resulting in a copayment amount of $3,496.
You have been asked to pay $0 copayment per day for days 1 to 20 and $184 copayment per day for days 21 to 100 for SNF stay. SNF stay falls within the Skilled Nursing Facility (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 skilled nursing facility (SNF) stay provided from July 1, 2021, to July 24, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the laboratory services (80061, 86870) provided from December 1, 2020, through December 31, 2020.  You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.  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 combined in-network and out-of-network deductible of $110. This is the amount you have to pay out-of-pocket before the plan will pay their share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Once you have paid your deductible, the plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the plan year. Additionally, there is a 15% coinsurance for Medicare-covered laboratory services.  You have been asked to pay $72.15 (36.06 + $36.09) for the laboratory services provided. This includes the billing of procedure code 80061 with the allowed amount of $13.39 applied to the deductible. This also includes the billing of procedure code 86872 with a deductible of $22.67 applied as you had not previously met the yearly deductible. The total deductible applicable was (13.39 + $22.67=$36.06). Additionally, code 86872 was processed as (the Plan allowed amount of $263.24 minus the $22.67 deductible=$240.57). The plan applied the cost sharing for this service as ($240.57 x 15% coinsurance=$36.09 liability). With the processing of this claim, you had now met the yearly deductible. 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 cost share for the laboratory services (80061, 86870) provided from December 1, 2020, through December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator.  You asked the Plan to pre-approve spinal cord stimulator. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not have an indication for which this may be covered.  The Plan follows Medicare rules. Medicare rules state that a spinal cord stimulator may be covered for certain specified indications.  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 spinal cord stimulator. Our reviewer says that the enrollee does not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer found there is no documentation of a surgical consultation, psychological evaluation, or multi-disciplinary approach to the enrollee's pain. The enrollee does not have an evidence-based indication for a spinal cord stimulator trial.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator.
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 want to know why your insurance isn't covering these benefits for your incontinence diapers and your back support protection supply. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan Solution 0.0015% for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested drug is not covered by the medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Zioptan Solution 0.0015%
for the enrollee.
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 the enrollee has exhausted conservative treatment options and recommend custom orthotics for stability and support. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from
January 8, 2021, through February 4, 2021.
You asked the Plan to waive the coinsurance for radiation therapy. The Plan denied your request. The Plan says the claims processed with the correct 20% coinsurance.
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 a 20% coinsurance for each visit for therapeutic radiology services (radiation). The enrollee has been asked to pay a 20% coinsurance, for each visit for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and supplies 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 coinsurance for radiation therapy provided from January 8, 2021, through 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 the enrollee has Painful calluses, Painful Fungal Toenail, Bilateral pes planus and flat feet with pain. 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on March 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 had network providers available who could have provided 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 the physician services provided on March 10, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673).  You asked the Plan to pay for a pneumatic compression device and appliance. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and appliance (E0673).
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 were diagnosed with polyneuropathy. 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on August 30, 2021.  You asked the Plan to pay for code 70544. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  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, we have confirmed that code 70544 is a column II code to column I code 70553. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on August 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided May 25, 2021.
You asked the Plan to waive the copayment for the ambulance transport and services. You say that the Plan representatives have provided contradictory and confusing information. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $235 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $235 copayment for the ambulance transport and services. The ambulance transport and services fall within the Ambulance 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 ambulance service, basic life support, emergency transport (A0429) provided May 25, 2021.
Your complaint about Plan representatives potentially providing contradictory and confusing information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation trips.  You asked the Plan to pre-approve additional routine transportation trips. You say that you require additional transportation. The Plan denied your request. The Plan says you ave exhausted your trips for this year.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty-two (32) trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the resin-based composites provided on February 8, 2021, February 18, 2021, and February 22, 2021.  You asked the Plan to pay more for the resin-based composites. You say that the amount they are reimbursing is less than 30% and you want to know if that is the amount they pay an in-network dentist. The Plan denied your request. The Plan says the services were properly paid toward your out-of-network benefits.  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 Plan is only obligated to pay 50% of the allowed amount for resin-based composites from an out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the resin-based composites provided on February 8, 2021, February 18, 2021, and February 22, 2021.