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

We decided that the Plan does not have to waive the copayment for the stress test provided on June 4, 2019.
You asked the Plan to waive the copayment for the stress test. You say that the cardiovascular stress test was unnecessary because you did not have the surgery and you were not provided another doctor. The Plan denied your request. The Plan says your copayment has been adjusted to the language of the Evidence of Coverage, which states there is a $40 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 $40 copayment for each diagnostic radiology service. You have been asked to pay a $40 copayment for the stress test. The stress test falls 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 the stress test provided on June 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Precision Xtra Blood Ketone Test Strips for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee cannot afford to buy these strips. The Plan denied your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and these services is an OTC item. Therefore, we decided that the Plan does not have to pre-approve Precision Xtra Blood Ketone Test Strips for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the endodontic nerve treatment (D3330) provided on October 28, 2019.
You asked the Plan to reimburse you for the dental service. The Plan denied your request. The Plan says the endodontic nerve treatment is not a covered 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, the endodontic nerve treatment is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the endodontic nerve treatment (D3330) provided on October 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for an the GI endoscopy provided on August 6, 2019.
You asked the Plan to waive the cost share for the upper GI endoscopy. You say that this was a necessary procedure and should not be charged this exorbitant fee. 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. Your contract with the Plan says that there is a $1,000 deductible that applies towards outpatient hospital services and a $195 copayment for an outpatient hospital surgery after you pay your $1,000 deductible. The upper GI endoscopy you asked the Plan to waive the cost share for falls within the "Outpatient hospital services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards outpatient hospital services. The record shows the allowed amount for the upper GI endoscopy is $1,574. Therefore, $1,000 was applied to your deductible.
You have also been asked to a pay a $195 copayment for the upper GI endoscopy. The record shows the remaining allowed amount is $574. Therefore, you are responsible for the $195 copayment.
This cost sharing is a contractual obligation that had not been met at the time the upper GI endoscopy was received on August 6, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the upper GI endoscopy provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on October 15, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you went for glaucoma testing. You say that you should not have acopayment.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 $50 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was for ocular hypertension and dry eyes. 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 forthe office visit provided on October 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pantoprazole for the enrollee.
You asked the Plan to pre-approve Pantoprazole. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
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 pre-approve Pantoprazole.
Benefits for Pantoprazole may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Gut Health Assessment - Film Array GI Pathogen test provided to the enrollee on November 28, 2018.
You asked the Plan to pay for the test. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational services are not covered.
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 pay for the test. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found this assessment focuses on panels combining investigation of bacteria, viruses and parasites and does not consider partial panels that could be combined to cover all pathogen groups. There was no specific clinical rationale provided for the requested study. Medical necessity for the requested lab study was not established. The requested item at issue in this case was not medically reasonable and necessary. 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 test have not been met. Therefore, we decided that the Plan does not have to pay for the Gut Health Assessment - Film Array GI Pathogen test provided to the enrollee on November 28, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora SNF stay from March 7, 2019 to April 12, 2019.You asked the Plan to waive the copayment fora SNF stay. You say that the enrollee should not be responsible for the charges due to the quality of wound care.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1-20 and a $172 copayment for days 21-100 for SNF care. The enrollee had a SNF stay from March 7, 2019 to April 12, 2019. The enrollee is not being charged a copayment for days 1-20 (March 7, 2019 to March 26, 2019). The enrollee isresponsible to pay a $172 copayment for days 21-36 (March 27, 2019 to April 11, 2019). $172 (copayment) x 16 (SNF days) = $2,752.00.The enrollee has been asked to pay the total copayment amount of $2,752.00 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora SNF stay from March 7, 2019 to April 12, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit us to make a decision on this type of complaint
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the plan will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level of care.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include ventricular assist device care, surveillance laboratory studies, continued anticoagulation, intravenous antibiotics, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit with the physician on November 1, 2019.
You asked the Plan to waive the deductible for an office visit. 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. Your contract with the Plan says that there is a $750 deductible for out-of-network physician/practitioner services, including doctor's office visits. You had and office visit with an out-of-network provider on November 1, 2019. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $149.14, which is less than the $750 deductible. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on November 1, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an office visit with the physician on November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bifocal lenses (V2202) purchased on July 17, 2019.
You asked the Plan to pay for the bifocal lenses. You say that as you went through the scheduling and
preparation for surgery there was no mention about any requirements to purchase your glasses with any
sourcing restrictions. The Plan denied your request. The Plan says the claim was processed correctly as the
enrollee did not purchase her eyewear from a plan optical facility.
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 when provided by a network provider.
We looked at the file and the Plan's rules. Vision services must be received from a network provider. Based on
this information, we decided that the Plan's rules for coverage of the bifocal lenses have not been met.
Therefore, we decided that the Plan does not have to pay for the bifocal lenses (V2202) purchased on July 17,
2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an acute inpatient hospital admission.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan
denied your request. The Plan says that the services are not medically necessary.
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 services are medically necessary. Our physician reviewer found the submitted records show that
you presented to the emergency room (ER) on January 5, 2020 with painful urination (dysuria) over three
weeks. You also had complaints of nausea and right-sided pain. Bacteria was found in the urine and you were
admitted and started on intravenous (IV) fluids and medications. The records support a reasonable expectation
that you would require at least two midnights of inpatient hospital care. The acute inpatient level of care is
medically necessary.
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 an acute inpatient hospital admission.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 16, 2019.
You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee's hospice did not authorize these services and these services were not part of the hospice plan of care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 30, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were not informed there would be a copayment and you are on a fixed income. 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 $350 copayment for in-network Medicare-covered outpatient diagnostic radiology services (such as MRIs and CT scans). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the CT scan.
You have been asked to pay a $246.93 copayment for the CT scan. The CT scan falls 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 the CT scan provided on September 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on July 16, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for radiology services. You say that you would like this claim reconsidered for the
correct reimbursement. The Plan denied your request. The Plan says no prior authorization was obtained for
these services.
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 has network providers
available who can provide 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 radiology services provided on July 16, 2019 by
an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee requires the acute level of care and is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services for the dental procedure you had on September 3, 2019.You asked the Plan to pay forthe anesthesia services. You say that this is necessary.The Plan denied your request. The Plan says this is not a covered service.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe anesthesia services for the dental procedure you had on September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe walker provided on July 1, 2019.You asked the Plan to waive the coinsurance forthe walker. You say that you were informed you had to pay $7.06. You say that you should not owe more than that.The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for each Medicare-covered item. You have been asked to pay $15.20, which is 20% of the allowed amount for the walker. The allowed amount is$76.02 (20% x $76.02 = $15.20). The walker falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is acontractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe walker provided on July 1, 2019.