Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ophthalmic imaging and eye surgery
provided on December 26, 2019.
You asked the Plan to waive the cost share for the ophthalmic imaging and eye surgery. You say that you
weren't advised of the extra expense. You say that you should only be responsible for the $40 copayment. The
Plan denied your request. The Plan says the cost share 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 15%
coinsurance for all other outpatient diagnostic tests and therapeutic services/supplies from an in-network
provider and $175 for Medicare-covered surgery services at an in-network ambulatory surgical center.
You have been asked to pay a total of $181.26 for the ophthalmic imaging and eye surgery.
Service Allowed Amount Standard Cost Share Member Liability
Ophthalmic Imaging $41.03 15% $6.26
Eye Surgery $253.99 $175 $175
TOTAL: $181.26
The ophthalmic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies"
benefit category. The eye surgery falls within the "Outpatient surgery, including services provided at hospital
outpatient facilities and ambulatory surgical centers" 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
cost share for the ophthalmic imaging and eye surgery provided on December 26, 2019.
Appeal type: Imaging
Decision: Unfavorable


 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh to be provided by an OON provider. You say that you prefer to have the service provided by the OON provider. The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met. 
 
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 a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815) to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on December 10, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you cannot afford to pay this copayment. 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 20% coinsurance for Medicare B Part chemotherapy and non-chemotherapy prescription drugs. You have been asked to pay $761.54 which was 20% of the allowed amount for the Part B injection. The allowed amount is $3,807.68. ($3,807.68 x 20% = $761.54). The Part B injection falls 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 the Part B injection provided on December 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99222) and ERCP (43264 and 43274) provided on June 15, 2019. 
 
You asked the Plan to pay for the hospital care and ERCP. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hospital care and ERCP have not been met. Specifically, the records submitted reference a different date of service than what was billed. There is insufficient information to verify the billed services. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) and ERCP (43264 and 43274) provided on June 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on November 7, 2019. 
 
You asked the Plan to waive the copayment for the endoscopy. You say that the procedure was not successful so you had to return. You say that you should only be responsible for one copayment. The Plan denied your request. The Plan says the copayment 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 $100 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. 
 
You have been asked to pay a $100 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the endoscopy was performed. 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 provided on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 22, 2020.You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work was a part of your annual physical and you should not have a copayment.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 $10 copayment for Medicare-covered laboratory tests. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that the laboratory work is considered a separate service.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided December 9 to December 18, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient services were medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 
 
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. The enrollee required intensive care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided December 9 to December 18, 2019. 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: 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 have neuropathy and you cannot stand for long periods of time. You say that you wife is also elderly and she cannot assist you while showering. You stated that you are currently confined to your home and not walking as much. You say that you are getting weaker and having a lot of trouble with showering. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radium treatment provided on January 7, 2020. 
 
You asked the Plan to waive the coinsurance for the radium treatment. You say that last year you had little to no copayment for the radium treatment. 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 20% coinsurance for Medicare Part B chemotherapy prescription drugs.  
 
You have been asked to pay $3,400 for the radium treatment. This is less than the standard coinsurance amount because you met your maximum out-of-pocket amount. The radium treatment falls within the "Medicare Part B prescription drugs" benefit category. The record shows the radium treatment is considered a Part B chemotherapy drug. 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 the radium treatment provided on January 7, 2020.  
 
Your complaint that the insurance representative was misleading 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on November 6,
2019 and November 14, 2019.
You asked the Plan to waive the copayment for laboratory tests. You say that this was your first PAP test of the
year. You say that you shouldn't have a $0 copayment. The Plan denied your request. The Plan says the
copayment 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 $20
copayment per visit for laboratory tests, non-radiological tests, diagnostic tests, flat film X-rays, and
ultrasounds.
You have been asked to pay a total of $31.63 for the laboratory tests. Laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The records show that diagnostic laboratory tests were performed. 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 tests provided on November 6, 2019 and November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on October 30, 2019. 
 
You asked the Plan to waive the copayment for the specialist visit. You say that you have already paid for the hospital services and lab copayment. You say that the specialist copayment should be covered. The Plan denied your request. The Plan says the copayment 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 $45 for each covered visit or consultation in an outpatient location with a specialist.  
 
You have been asked to pay a $45 copayment for the specialist visit. The specialist visit falls within the "Physician/Practitioner services, including doctor's office 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 copayment for the specialist visit provided on October 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 17, 2019. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you are submitting your bill for review. You say it was not paid because the doctor did not submit an authorization number. 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 $200 copayment per one-way trip.  
 
You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls 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 ride provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 3, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like reconsideration for payment because you are contracted with the skilled nursing facility. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that 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. Therefore, we decided that the Plan does not have to pay for lab work provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on September 23, 2019. 
 
You asked the Plan to pay for the office visit. You say that the referral clearly states the requested provider. The Plan denied your request. The Plan says that the pre-certification is exceeded. 
 
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 records show that an authorization for 1 visit was obtained for the provider at issue in this case. The records do not show that the authorization has already been used. There is no evidence to show the authorization benefits have been exceeded. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the office visit provided on September 23, 2019.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Dental X-rays (D0220, D0230) provided February 4, 2020.
You asked the Plan to pay for the Dental X-rays. You say that the service should be covered. The Plan denied
your request. The Plan says coverage is limited to a single set of x-rays each 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 the Dental Xrays
once per year.
We looked at the plan contract, the file, and Medicare rules. The record shows the enrollee already had one set
of intraoral X-rays this year. Based on this information, we decided that the Plan's rules for coverage of the
Dental X-rays have not been met. Therefore, we decided that the Plan does not have to pay for Dental X-rays
(D0220, D0230) provided February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553) provided
October 15, 2019.
You asked the Plan to pay for the continuous glucose monitor supply allowance. You say that the items
provided were medically necessary. The Plan denied your request. The Plan says the records do not support the
services 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.
We find that CPT code K0553 is not supported in the medical record. Specifically, the medical records
provided do not support the diagnosis code submitted by the supplier. Based on this information, we decided
that Medicare rules for coverage of the continuous glucose monitor supply allowance have not been met.
Therefore, we decided that the Plan does not have to pay for supplies for a continuous glucose monitor (K0553)
provided October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833), lumbar-sacral orthosis
(L0650) and suspension sleeves (L2397) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is
medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of
an established relationship between the member and the ordering physician. The Plan states there were no
claims submitted for an evaluation and management service. The Plan states the review of claims history for
this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine
or Telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses
(L1833), lumbar-sacral orthosis (L0650) and suspension sleeves (L2397) provided to the enrollee on August
19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no evidence that the enrollee requires services that are not currently available.
As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.