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

 We decided that the Plan does not have to pay for the breast prosthesis/mastectomy bra provided by non-Medicare providers on July 3, 2021.  You asked the Plan to pay for the breast prosthesis/mastectomy bra provided by non-Medicare providers. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this item is not covered when provided by a provider that is not enrolled in the Medicare program.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the providers at issue are not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the breast prosthesis/mastectomy bra provided by non-Medicare providers on July 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the chest x-ray you had at a freestanding radiology facility on July 8, 2021.  You asked the Plan to waive the copayment for the chest x-ray. You say that this x-ray is a part of your annual physical. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($35.12) is less than your copayment obligation, you are responsible for the full allowed 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 $50 copayment for basic radiology services at a freestanding radiological facility.   You have been asked to pay a $50 copayment for the chest x-ray. According to your contract, an annual wellness visit includes services to develop or update a personalized prevention plan based on your current health and risk factors.  It does not include diagnostic testing such as x-rays, so separate cost sharing can apply. 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 chest x-ray you had at a freestanding radiology facility on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided there is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your level of disability and pain. Care at the skilled nursing facility level appears to be appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for air ambulance provided on March 31, 2021  You asked the Plan to pay for the air ambulance. You say that air ambulance transport was medically necessary. The Plan denied your request. The Plan says the transportation was medically necessary, however the flight only reduced transportation time by ten minutes and did not justifiably reduce the enrollee risk when ground transport was only expected to be 22 minutes. To justify the flight, the transportation should exceed 30 to 60 minutes.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 pay for the air ambulance. Our reviewer says that air ambulance was not medically necessary. Our physician reviewer found that transportation was medically necessary, and enrollee did require intubation, however use of air transport generally should exceed 30 to 60 minutes. Ground transport in this case would have been approximately 22 minutes; helicopter flight time was 12 minutes. Shortening travel time by 10 minutes does not appear clinically meaningful such that it would justify the added risk of air transport vs ground. The review has determined that the documentation did support that the enrollee suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation does not support that the enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by ground posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation did support that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance provided on March 31, 2021
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health aide (HHA) services.  You asked the Plan to pre-approve the HHA care. You say that the enrollee is not able to care for himself and needs someone there to assist as he recovers from the stroke. The Plan denied your request. The Plan says the enrollee is not receiving skilled care from a nurse or therapist. As such, HHA care is not covered.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   There is no evidence that it is medically necessary for the enrollee to have skilled nursing or skilled therapy services in the home. As such, home health aide services cannot be covered. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) services.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the magnetic resonance angiography and the duplex scan of extracranial arteries provided from July 28, 2021 to July 30, 2021.  You asked the Plan to pay for the magnetic resonance angiography and the duplex scan of extracranial arteries. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services provided are not a covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan states that per LCD or NCD guidelines, a diagnosis code(s), which meets medical necessity for the procedure code is missing or invalid. There is no other documentation provided with the case file. An initial decision letter was not provided with this case file. No Medicare rules/guidelines were provided that were used to come to this decision. This means that the Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the magnetic resonance angiography and the duplex scan of extracranial arteries provided from July 28, 2021 to July 30, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiologic exam (72050) provided on July 21, 2021.  You asked the Plan to pay for the radiologic exam. 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 when provided by a chiropractor.  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. Radiology services are not covered by Medicare when provided by a chiropractor as in this case. Therefore, we decided that the Plan does not have to pay for the radiologic exam (72050) provided on July 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from June 28, 2021, to July 12, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you are allergic to pain medications. You say that only other option was Tylenol. You also say that since this was the only option, it should be covered. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from June 28, 2021, to July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for services you received with an out-of-network gynecologist on July 2, 2020.  You asked the Plan to waive the coinsurance for the out-of-network gynecology services. You say that this doctor was rude and caused you pain during your visit.  You stated that your pessary fell out after the visit, so you do not think this doctor should be paid. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance for out-of-network specialist services.   You have been asked to pay 30% coinsurance for the out-of-network gynecology services.  This cost sharing applies regardless of your satisfaction with the services received. 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 services you received with an out-of-network gynecologist on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the spinal injection procedure you had at an outpatient hospital facility on July 19, 2021.  You asked the Plan to waive the copayment for the spinal injection procedure. You say that this injection was required by Medicare before your upcoming surgery.  You stated that you disagree with the copayment. The Plan denied your request. The Plan says you were initially incorrectly charged two $225 copayments for this service.  That has been adjusted and you now owe only one copayment.  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 $225 copayment for outpatient surgery.   You have been asked to pay a $225 copayment for the spinal injection procedure.  The injection you received is considered a surgical service. 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 spinal injection procedure you had at an outpatient hospital facility on July 19, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Botox 200 Unit vial.  You asked the Plan to pre-approve Botox 200 Unit vial. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary.  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 Botox 200 Unit vial. Our reviewer says that the documentation does support that the requested drug is medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of chronic migraine. The Food and Drug Administration (FDA) has stated that the requested drug is indicated for the enrollee's condition. The plan states that there is a dosing interval limitation. Dosing instructions are not binding upon the determination of whether a medically accepted indication is present and is therefore, not controlling upon coverage determination. The elements of the coverage criteria are satisfied. Therefore, the enrollee meets criteria for the requested Botox.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox 200 Unit vial have been met. Therefore, we decided that the Plan has to pre-approve Botox 200 Unit vial.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for DMPK (DM1 protein kinase) gene analysis (81234) provided on July 6, 2021.  You asked the Plan to pay for DMPK gene analysis. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code 81234 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary.  We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we decided that Medicare rules for coverage of DMPK gene analysis have not been met. Therefore, we decided that the Plan does not have to pay for DMPK (DM1 protein kinase) gene analysis (81234) provided on July 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on August 28, 2020.  You asked the Plan to waive the copayment for laboratory services. You say that you paid the laboratory services and disagree with how the claims were processed over a year later. 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 $20 copayment for laboratory services.   You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall 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 copayment for laboratory services provided on August 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory viral panel testing provided on July 27, 2021.
You asked the Plan to pay for viral panel testing. You say that you performed the testing requested by the ordering physician. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was performed for screening purposes and viral pathogen panels of 6 or more targets are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Without an order, it cannot be determined whether this testing was ordered for Medicare-covered purposes. Based on this information, we decided that Medicare rules for coverage of viral panel testing have not been met. Therefore, we decided that the Plan does not have to pay for respiratory viral panel testing provided on July 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the chest x-ray you had on July 14, 2021.  You asked the Plan to waive the deductible for the chest x-ray. You say that you were told that you would not be responsible for this bill. The Plan denied your request. The Plan says you were assessed this deductible correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 copayment which applies to basic imaging services.   The chest x-ray falls within the benefit category of basic imaging services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 copayment which applies to basic imaging services. This cost sharing is a contractual obligation that had not been met at the time the chest x-ray was received on July 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the chest x-ray you had on July 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair van provided on June 24, 2021.
You asked the Plan to pay for the wheelchair van. You say that the service was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the wheelchair van provided on June 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 18, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you feel that you should not be responsible for the copayments since the transport was not your choice. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees 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 $225 copayment per one-way trip for emergency and non-emergency ambulance services.
You have been asked to pay a $225 copayment for the ambulance services. Ambulance 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 ambulance services
provided on May 18, 2021.
Your complaint about your family not being allowed to transport you 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.