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

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received on April 3, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $110 copayment per visit for emergency room services.
You have been asked to pay a $110 copayment per visit for the ER visit. 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 emergency room (ER) services you received on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on March 5, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that you were not aware a network provider was 
required, and you are requesting reimbursement. The Plan denied your request. The Plan says the hearing aids 
were purchased from a provider outside of the network. 
 
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 they are received from a network provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular panel testing provided on January 28, 2021.
You asked the Plan to pay for the testing services. You say that the services in question were medically necessary. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels for those with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. In this case, there were insufficient medical records that showed the results of the testing would be used in the determination of a specific diagnosis or treatment strategy. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular panel testing provided on January 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the chemotherapy drugs provided on 
January 14, 2021. 
 
You asked the Plan to reduce the coinsurance for the chemotherapy drugs. You say that the costs of this 
treatment were much less under your State insurance plan, so you would like the claim adjusted. The Plan 
denied your request. The Plan says this coinsurance was charged correctly. The Plan says that the allowed 
amount for the chemotherapy drugs received is $20,259.20, so 20% coinsurance equals $4,051.84. 
 
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 20% coinsurance for Medicare Part B drugs.  
 
The enrollee has been asked to pay 20% coinsurance for the chemotherapy drugs. The chemotherapy drugs fall 
within the Medicare Part B drugs 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 reduce the 
coinsurance for the chemotherapy drugs provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and diagnostic procedure provided on April 27, 2021.

You asked the Plan to waive the copayments for the specialist office visit and diagnostic procedure. You say that you do not agree with the amount of the copayments. The Plan denied your request. The Plan says you were charged the copayments 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 $40 copayment for Specialist Physician Services and a $50 copayment for Outpatient Diagnostic Tests.

You have been asked to pay a $40 copayment for Specialist Physician Services and a $43.86 copayment for scanning computerized ophthalmic diagnostic imaging. The copayment for the scanning computerized ophthalmic diagnostic imaging is less than the required copayment because the Medicare allowable for this procedure is $43.86. 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 specialist office visit and scanning computerized ophthalmic diagnostic imaging provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 8, 2021, to April 16, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you are being charged for an additional day incorrectly and would like the cost share adjusted. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $403 copayment per day, for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that for days 6 and beyond, you pay a $0 copayment for inpatient hospital care.

You have been asked to pay a $403 copayment per day, for days 1-5 for inpatient hospital care. The records show you were in the hospital from April 8, 2021 to April 16, 2021. The EOC confirms that $403 per day, for the first 5 days, is the required copayment for this service. Your total cost-share is $2,015 ($403 x 5 days = $2,015). 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 on April 8, 2021, to April 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on March 11, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you did not receive the services. 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 $50 copayment for diagnostic radiology services. The medical records show that you received an ultrasound on March 11, 2021. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for an ultrasound. An ultrasound 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 an ultrasound provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that this is medically necessary for the enrollee's pain. The Plan denied your request. The Plan says the requested procedure has not been shown to provide a clear long-term benefit over standard treatment for chronic SI joint pain.
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 radiofrequency ablation to the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide variation in efficacy in the literature. Therefore, the request is considered not medically reasonable or necessary 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 radiofrequency ablation to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 9, 2020 to July 13, 2020 by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for drug testing. You say that this drug testing is medically necessary. The Plan 
denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-
of-network with the Plan and authorization was not 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 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 drug testing provided on July 9, 2020 to July 13, 
2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission provided from April 10, 2021, to April 11, 2021.
You asked the Plan to waive the copayment for the inpatient admission. You say that you should not be responsible for the copayment because this inpatient admission was unnecessary. The Plan denied your request. The Plan says you have been asked to pay 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 $250 copayment per in-network admission.
You have been asked to pay a $250 copayment for the inpatient admission. The inpatient admission falls within the "Inpatient hospital care" benefit category. The record shows you received services during your inpatient admission. 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 inpatient admission provided from April 10, 2021, to April 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88341) provided to the enrollee on
January 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the denied code was billed without an appropriate primary code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 88341 is "Immunohistochemistry or
immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in
addition to code for primary procedure)."
We find that CPT code 88341 is not supported in the medical record. Specifically, this code cannot be billed
separately without a primary procedure. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for
laboratory services (88341) provided to the enrollee on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro upper extremity orthosis.

You asked the Plan to pre-approve MyoPro orthosis. You say that this device is the best option for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because there is insufficient evidence to assess the safety and/or impact on health outcomes associated with the use of this device.

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 MyoPro orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is not known to be effective based on scientific evidence, professional standards, and expert opinion in improving health outcomes in stroke patients. This device is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that this will improve the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe for long-term use.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro upper extremity orthosis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series x-ray (D0210), and the scaling and root planing (D4341 x 2) provided on April 16, 2021.
You asked the Plan to pay for the dental services. You say that the scaling and root planing was not completed. You say that your dentist took x-rays, then sent you to a specialist who took their own x-rays. You say that you just keep getting bills in the mail. You also say that you cannot afford these bills. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service. The Plan says that scaling and root planing is not listed as a covered service. The Plan also says that your other issues will be addressed in a separate letter.
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 complete series x-ray and scaling
and root planing are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the complete series x-ray (D0210), and the scaling and root planing (D4341 x 2) provided on
April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for flushable wipes, any hygienic item, device (A9286) 
purchased April 12, 2021. 
 
You asked the Plan to pay for flushable wipes. You say that you order these items regularly and they were 
covered in the past. The Plan denied your request. The Plan says this is a hygienic item and is not covered. 
 
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 pay for flushable wipes, any hygienic item, device (A9286) purchased 
April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on April 21, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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. We have also determined that these services are not urgent or emergent, nor were
they approved in advance.
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
physician's 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 physician's services provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on February 25, 2021. 
 
You asked the Plan to pay for the testing services. You say that the medical documentation supports the billing. 
The Plan denied your request. The Plan says the documentation did not contain a signed physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating 
the beneficiary are not reasonable and necessary. We looked at the file and the rules. In this case, we find that the testing is not supported in the medical record. 
The records provided do not clearly document the physician's intent for the testing to be performed. Based on 
this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab testing services provided on February 25, 
2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that your girlfriend would not know what to do if you took a fall. You say that the requested rehabilitation care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can be met with home health services or in an assisted living facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications, had stable vital signs, and was treated for pain. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at a supervision level with functional mobility, including gait to 20 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. However, these needs are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating provider on April 19, 2021.
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you were told that your copayment would be $245. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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% coinsurance for outpatient surgery/in-network/outpatient hospital.
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $11,438.44. The total amount you are being asked to pay for the outpatient surgery is $2,287.69 ($11,438.44 x 20% = $2,287.69). The correct coinsurance has been applied to the surgery that was provided. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital 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 an outpatient surgery provided by a participating provider on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (85060) provided on December 28, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable. 
 
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 code 85060is not supported in the medical record. Specifically, code 85060 has a PC/TC indicator 
of "8". This means that payment cannot be made for services furnished to hospital outpatients or non-hospital 
patients. Based on this information, we decided that Medicare rules for coverage of the services have not been 
met. Therefore, we decided that the Plan does not have to pay for the services (85060) provided on December 
28, 2020.