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

We decided that the Plan does not have to waive the copayment for the ultrasound (echocardiography) of the heart (93306) provided on September 21, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you are upset by the cost of this service and do not understand why the Plan is paying less of the cost than you are. The Plan denied your request. The Plan says radiological diagnostic services, such as an ultrasound, are subject to a $155 copayment. The cost-sharing was 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 $155 copayment for outpatient radiological diagnostic services. You have been asked to pay a $155 copayment for the ultrasound. The provider billed the Plan $780 for this service, but the Plan's allowed amount (the amount they agreed to let the provider be paid) is $243.21. Your contract with the Plan states that you must pay a $155 copayment for outpatient radiological diagnostic services, and the Plan will cover the rest. A copayment is a fixed amount charged to you on a per-service basis. 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 ultrasound (echocardiography) of the heart (93306) provided on September 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and ultrasounds provided by a participating provider on October 19, 2020.
You asked the Plan to waive the copayment for an office visit and ultrasounds. You say that you would like the Plan to pay the rest of this claim. The Plan denied your request. The Plan says the correct copayments have 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 $45 copayment for physician/practitioner services/specialist and a $155 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay a $45 copayment for an office visit and a $155 copayment for ultrasounds.
CPT Code
Copayment
Amount Being Charged
99214
$45
$45
93976
$155
$155
76870
$155
$98.74
76775
$155
$54.33
76857
$155
$44.77
Total Amount Being Asked to Pay: $397.84 ($45 + $155 + $98.74 + $54.33 + $44.77 = $397.84 = $397.84)
An office visit falls within the physician/practitioner services/specialist benefit category and ultrasounds falls within the outpatient diagnostic tests/radiological diagnostic 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 an office visit and ultrasounds provided by a participating provider on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this is the most appropriate treatment for the enrollee and does meet the requires for medically reasonable and necessary. The Plan denied your request. The Plan says the denial of authorization for this procedure is correct, because studies have not proven that Vertiflex is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental/investigational because it is not clear where it fits into accepted back pain algorithms. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require supervision by a rehab physician and an intensive interdisciplinary team.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for cervical diskectomy and fusion. Post-operative complications have included gastrointestinal bleeding and newly diagnosed diabetes. His medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, or an intensive rehabilitation therapy program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on November 13, 2019.
You asked the Plan to pay for the mammogram. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
mammogram. 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 a mammogram provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens upgrades you received on September 11, 2020.
You asked the Plan to pay for the lens upgrades. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Medicare only covers one pair of standard eyeglasses after cataract surgery. Lens upgrades are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the lens upgrades you received on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on August 10, 2020.
You asked the Plan to waive the coinsurance for DME. You say that you did not request the equipment nor want it. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. The record shows that you received DME on August 10, 2020. The allowed amount is $2,925.60 and 20% of that is $585.12. You have been asked to pay the total coinsurance amount of $585.12 for DME. DME falls within the 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 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 DME provided on August 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance services
were medically necessary The Plan denied your request. The Plan says the correct cost share applied to the
claim.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment for ambulance services.
You have been asked to pay a $225 copayment for the ambulance services. These services fall 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
services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiology office visit provided on November 9, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that you feel this was just a primary care provider visit and not a specialist. The Plan denied your request. The Plan says the copayment amount 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 $40 copayment for specialist visit. This provider is a cardiology specialist; therefore, the specialist visit copayment applies to this claim. You have been asked to pay $40 copayment for specialist visit. 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 a cardiology office visit provided on November 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection.

You asked the Plan to waive the copayment for an epidural injection. You say that you were not aware that you would owe such a high copayment and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $295 copayment for an epidural injection. An epidural injection falls within the outpatient surgery and other medical 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 copayment for an epidural injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chiropractic services provided from November 10, 2020, to November 25, 2020.
You asked the Plan to waive the copayments for chiropractic services. You say that you thought that all specialist copayments were waived due to COVID-19. 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 $15 copayment for chiropractic services. You received chiropractic services from November 10, 2020, to November 25, 2020, for a total of 3 visits. The record shows that chiropractic services are not included in the copayment waiver. Therefore, you are responsible to pay a $15 copayment per each visit. The total amount you owe is: $15 (copayments) x 3 (chiropractic visits) = $45. You have been asked to pay the total copayment amount of $45 for chiropractic services. Chiropractic services fall within the chiropractic 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 chiropractic services provided from November 10, 2020, to November 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for X-Ray services provided on November 7, 2020.
You asked the Plan to waive the deductible for X-Ray services. You say that you were surprised to owe this amount and would like to have it waived. The Plan denied your request. The Plan says the deductible amount you are being charged is correct.
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 $250 deductible for X-Ray services. The allowed amount of this claim is $77.32, resulting in a deductible obligation of $77.32. The items or services you asked the Plan to waive the deductible for fall within the benefit category Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $250 deductible for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the time X-Ray services were received on November 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for X-Ray services provided on November 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for walker. You say that federal laws state that Medicare Advantage organizations should pay non-contracted providers as original Medicare would. The Plan denied your request. The Plan says the denial of payment for this item 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 the medical services provided on August 25, 2020 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 shower chair.
You asked the Plan to pre-approve a shower chair. You say that you need this item for assistance in the shower. The Plan denied your request. The Plan says this is not a covered service.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided by an out of network (OON) provider.

You asked the Plan to pay for assisted living services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are no referring providers on file 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 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 assisted living services provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for x-rays and coinsurance for ankle durable medical equipment provided by a participating provider on July 9, 2020.
You asked the Plan to waive the copayment for x-rays and coinsurance for ankle durable medical equipment. You say that you think that these charges should be waived. The Plan denied your request. The Plan says the correct copayments and 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 $14 copayment for outpatient diagnostic tests/x-rays and a 20% coinsurance for durable medical equipment. You have been asked to pay a $14 copayment for x-rays and a 20% coinsurance of the allowed amount for ankle durable medical equipment. The total allowed amount is $55.99. The amount you are being asked to pay for durable medical equipment is $11.20 ($55.99 x 20% = $11.20). The total amount you are being asked to pay is $39.20 ($14 + $14 + $11.20 = $39.20). X-rays falls within the outpatient diagnostic tests/x-rays benefit category and ankle durable medical equipment falls within the durable medical equipment 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 x-rays and coinsurance for ankle durable medical equipment provided by a participating provider on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room and lab services provided on August 12, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim was not billed in accordance with the guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim provided does not show that the services were reported with the correct code. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room and lab services provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no evidence of
an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the services provided
on October 2, 2020.