Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids (V5050) provided on April 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to reimburse you for hearing aids. You say that you do not agree with the denial. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from an out-of-network provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids (V5050) provided on April 21, 2021, 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 specialist office visit received on March 18, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you would like reimbursement for the money you paid out of pocket for these services. The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.
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 $25 copayment for each Medicare-covered specialist visit.
You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls within the physician/practitioner 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 specialist office visit received on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (80048) provided on June 16, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you feel the services should be covered as you went in for the same laboratory test last year and were not charged a copay. The Plan denied your request. The Plan says the copayment applied correctly based on the services rendered and that the record shows you were assessed the same $10 copayment for last year's visit.
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 $10 copayment for Outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The services at issue are not one of Medicare's preventative services with zero cost-sharing. 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 (80048) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0013M) provided April 16, 2021.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this test is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for procedure codes 0012M and 0013M for CxBladder. We looked at the file and Medicare rules. The code billed is 0013M. This code is non-covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0013M) provided April 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0480) rendered by the out-of-network (OON) provider on June 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug testing (80307, G0480) rendered by the out-of-network (OON) provider on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on April 15, 2021 to May 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic 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 received were neither emergent nor urgent and prior authorization was not obtained to seek 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 chiropractic services provided on April 15, 2021 to May 3, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Becton Dickinson sponge.
You asked the Plan to pre-approve a Becton Dickinson sponge. You say that the item is 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 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 Becton Dickinson sponge.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 7, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an office visit provided by a specialist on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 specialist visits. We looked at the file, the Plan's contract and Medicare rules. The file shows that you had a specialist office visit on April 7, 2021. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner 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 specialist office visit provided on April 7, 2021.
Your complaint about the how the visit should not be considered an office visit 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks.
You asked the Plan to pre-approve facet blocks. 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 follows Medicare rules. Medicare rules say that A second confirmatory diagnostic facet joint procedure is considered medically reasonable and necessary when specific criteria are met. 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 facet blocks. Our reviewer says that the
services are not medically necessary. Our physician reviewer found in this case; the first diagnostic facet injection resulted in 50% improvement in pain. After the first diagnostic facet joint procedure, there must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief being consistent with the agent used). The review has determined that you do not meet the coverage criteria detailed in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet blocks.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care
provided from December 1, 2020 to December 20, 2020.
You asked the Plan to waive the copayment for the SNF care. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received SNF care on the dates of service at issue in this appeal. The Plan says
that the correct copayment has applied per your contract with the Plan.
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 per day for days 1-20 and a $178 copayment per day for days 21-100 for Skilled nursing facility
(SNF) care.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received SNF care from
November 24, 2020 through December 20, 2020. You have been asked to pay a $0 copayment for days 1-20
and a $178 copayment per day for days 21-27, totaling $1246. The SNF care 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 the skilled nursing
facility (SNF) care provided from December 1, 2020 to December 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (81002) rendered by the out-of-network (OON) provider on March 17, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and the laboratory service (81002) rendered by the out-of-network (OON) provider on March 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided from April 28, 2021, to April 30, 2021.
You asked the Plan to waive the copayment for emergency room services. You say that you told the provider you wanted to be admitted. You also say the provider gave you every impression that they were admitting you and not putting you in observation. The Plan denied your request. The Plan says you were 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 $50 copayment for emergency care.
You have been asked to pay a $50 copayment for emergency room services. The record indicates that the provider billed outpatient 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 emergency room services provided from April 28, 2021, to April 30, 2021.
Your complaint about potentially being informed that you were admitted 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided from July 1, 2021 to July 13, 2021.
You asked the Plan to waive the copayment for the SNF care. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received SNF care on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $184 copayment per day for days 21-100 for Skilled nursing facility (SNF) care.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received 22 days of SNF care provided from June 21, 2021 through July 13, 2021. You have been asked to pay a $0 copayment per day for days 1-20 and a $184 copayment per day for days 21-22, totaling $368. The SNF care 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 the skilled nursing facility (SNF) care provided from July 1, 2021 to July 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits.
You asked the Plan to pre-approve 2 home health skilled nursing visits. 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 home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 2 home health skilled nursing visits.
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee
does not have documented skilled nursing needs. As such, the requested, ongoing, home health skilled nursing
services are not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 2 home health skilled nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 2 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a refraction (92015) provided on May 21, 2021.
You asked the Plan to pre-approve a refraction. You say that this should be covered. The Plan denied your request. The Plan says this was not provided by a network routine vision care provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services during a routine exam when provided by a network routine vision care provider. We looked at the file and the Plan's rules. The record does not show that this refraction was provided during a routine exam by a network routine vision care provider. Based on this information, we decided that the Plan's rules for coverage of a refraction have not been met. Therefore, we decided that the Plan does not have to pre-approve a refraction (92015) provided on May 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. 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 follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. 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 a portable ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Determination (LCD): Respiratory Assist Devices (L33800). Records do not document why a bilevel positive airway pressure (BiPAP) device with average volume assured pressure support would not meet the enrollee's needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from June 1, 2021 to June 17, 2021.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received physical therapy services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physical therapy visits from June 1, 2021 to June 17, 2021. You have been asked to pay a $40 copayment for each physical therapy visit, totaling $160. The physical therapy visits fall within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the physical therapy visits provided from June 1, 2021 to June 17, 2021.
Your complaint about not being satisfied with the services you received 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nulojix.
You asked the Plan to pre-approve Nulojix. 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 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 Nulojix. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review indicates that the documentation does not support that the Nulojix is medically reasonable and necessary for the enrollee. The documentation does not support that the Nulojix is safe and effective for 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 Nulojix have not been met. Therefore, we decided that the Plan does not have to pre-approve Nulojix.