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

We decided that the Plan does not have to waive the coinsurance for family medicine services you received
from an out-of-network provider on May 21, 2021.
You asked the Plan to waive the coinsurance for the family medicine services. You say that you did not have
services on this date. 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 20%
coinsurance for primary care doctor visits.
You have been asked to pay 20% coinsurance for the family medicine services. We looked at the medical
records from this date of service to confirm you were seen. The records show that you were seen on this date
by this provider and you discussed at this visit you transitioning from being her physician. So, the records
confirm that you did receive services on this date. The family medicine services fall within the primary care
doctor visits 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 family medicine services
you received from an out-of-network provider on May 21, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675).  You asked the Plan to pay for a pneumatic compression device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is not medically necessary or reasonable.  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).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on April
19, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not informed
that you would owe anything beyond the outpatient stay and disagree with the additional 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 20%
coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs on April 19, 2021. The total allowed amount is $607.71 and 20% of that is
$121.54.
You have been asked to pay the total coinsurance amount of $121.54 for Medicare Part B drugs. Medicare Part
B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on April 19, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy services you received from May 3, 2021, to May 28, 2021.
You asked the Plan to waive the coinsurance for the radiation therapy services. You say that you were never told how much the cost would be. You said that because you weren't provided this information, you were not able to inquire about alternate treatments or providers. 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 20% coinsurance for radiation therapy. You have been asked to pay 20% coinsurance for the radiation therapy 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 coinsurance for radiation therapy services you received from May 3, 2021, to May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). The Plan denied your request. The Plan says the certification dated November 3, 2021, documented that the enrollee has none of the qualifying diagnoses, does not require intense care coordination, and has no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. 

We looked at the file and Plan's rules. The file shows that your medical conditions are not eligible medical conditions for coverage under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested
item.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent
self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we
decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided
that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex interspinous spacer.
You asked the Plan to pre-approve Vertiflex interspinous spacer. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 Vertiflex interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has persistent back pain. Interlaminar devices remain experimental in spinal surgery more research. Is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675).

You asked the Plan to pay for a pneumatic compression device. You say that this item should be covered. The Plan denied your request. The Plan says this device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.

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).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablations.
You asked the Plan to pre-approve radiofrequency ablations. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months for each spinal region. We looked at the file and Medicare rules. Review of the file shows that the enrollee had radiofrequency ablation in June 2021. This means that the enrollee has already received two radiofrequency sessions in the previous 12 months. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power standing system, power seat elevation system, and push handles.

You asked the Plan to pre-approve power standing system, power seat elevation system, and push handles. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that power seat elevation and power standing systems are non-covered. 
The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

We looked at the file and Medicare rules. Power seat elevation and power standing systems are non-covered. The requested push handles at issue in this appeal does not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of power standing system, power seat elevation system, and push handles have not been met. Therefore, we decided that the Plan does not have to pre-approve power standing system, power seat elevation system, and push handles.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal maintenance (D4910) provided by a participating provider.

You asked the Plan to pre-approve periodontal maintenance. You say that you would like the Plan to approve these services. The Plan denied your request. The Plan says the benefit for D4910 has already been exhausted this calendar year.

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. The Plan covers periodontal maintenance when the services are medically necessary and reasonable. 

We looked at this physician's review, the file, and Medicare rules. Evidence was provided to show that periodontal maintenance was provided on April 30, 2021, and July 21, 2021. Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance have not been met. Therefore, we decided that the Plan does not have to pre-approve periodontal maintenance (D4910) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve in-network benefit coverage for a wig.  You asked the Plan to pre-approve the wig. You say that there are no providers in the network. The Plan denied your request. The Plan says neither Medicare nor the plan covers this 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 in-network benefit coverage for a wig.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns (D2740) and core buildup (D2950).
You asked the Plan to pre-approve the crowns (D2740) and core buildup (D2950). The Plan denied your request. The Plan says the services are not covered 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the crowns (D2740) and core buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insulin pump supplies to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve insulin pump supplies. You say that you would like to use this OON provider but cannot afford the coinsurance for the OON supplies. The Plan denied your request. The Plan says the requested services can be provided by a network provider to be provided at a lower cost share rate.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. We also note that while you may receive the requested supplies by an OON provider, the cost share requirement is higher. Therefore, we decided that the Plan does not have to pre-approve insulin pump supplies to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy of the anus you had at an
outpatient hospital facility on June 28, 2021.
You asked the Plan to waive the copayment for the endoscopy. You say that this is a diagnostic procedure
which is for preventative care. You stated that the Plan should pay for this. The Plan denied your request. The
Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this
procedure ($105.00) 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 $250
copayment for outpatient surgery and other services at an outpatient hospital facility.
You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the outpatient
surgery and other services at an outpatient hospital facility 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 endoscopy of the anus you had at an outpatient hospital facility on June 28,
2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4).
You asked the Plan to pre-approve the gingival irrigations. The Plan denied your request. The Plan says gingival irrigation is not a covered service under the enrollee's benefit plan.
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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four gingival irrigations (D4921 x4
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. The Plan denied your request. The Plan says this service is allowed one time in 5 calendar years. The Plan also says that the enrollee has already received this service within the past 5 years and has reached the limit for this service.
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, maxillary partial denture (D5213) is limited to 1 per 5 calendar years. The record shows that the enrollee received a maxillary partial denture (D5213) on August 20, 2019 and the enrollee's maxillary partial denture (D5213) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from
March 6, 2021, to March 16, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. 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 $225
copayment for days 1-7 for inpatient hospital care.
You received inpatient hospital care from March 6, 2021, to March 16, 2021. Therefore, you are responsible to
pay a $225 copayment for days 1-7 (March 6, 2021, to May 12, 2021). The total amount you owe is: $225
(copayment) x 7 (inpatient days) = $1,575.
You have been asked to pay the total copayment amount of $1,575 for inpatient hospital care. Inpatient hospital
care 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 inpatient hospital care provided from March 6, 2021, to March 16, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on August 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that the provider was non-participating but submitted re-credentialing and would like the claim reconsidered. 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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) provider