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 visit provided on March 29, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted to the emergency room and had blood drawn. You say you did not see any doctor or nurse. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. The record shows you received services during your emergency room 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 visit provided on March 29, 2019.
Your complaint that this is a complete rip-off 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 24, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that your evidence of coverage says that there is no copayment or coinsurance for a colonoscopy. 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 $250 copayment for each Medicare-covered, in-network, ambulatory surgical center service. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed, which makes this a surgical procedure. 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 colonoscopy provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe comprehensive evaluation provided on October 4, 2019.You asked the Plan to waive the copayment forthe comprehensive evaluation. You say that this was an annual gynecology checkup. You say that annual checkups are included.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrolleesin 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 $35 office visit copayment if services are provided by a specialist. You have been asked to pay a $35 office visit for the comprehensive evaluation. The comprehensive evaluation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider specializes in obstetrics and gynecology. 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 comprehensive evaluation provided on October 4, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cialis
You asked the Plan to pre-approve Cialis. You say that the enrollee has been on this medication since 2016. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Tadalafil (Cialis)
Benefits for Cialis 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need oxygen to go to the grocery store or church. The Plan denied your request. The Plan says your home oxygen system meets your needs within your home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The item at issue in this appeal is for use outside of the home The record shows that you have a stationary oxygen system with refillable portable tanks. This stationary oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee x-ray provided on November 21, 2019.
You asked the Plan to waive the copayment for the knee x-ray. You say that you were informed there would not be another charge for additional x-rays. You say that you cannot afford the bill. 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 basic imaging service. You have been asked to pay a $50 copayment for the knee x-ray. The knee x-ray 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 knee x-ray provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the skin laser treatment provided on December 6, 2019.
You asked the Plan to reduce the copayment for the skin laser treatment. You say that you should only be charged the office visit copayment instead of a $173.40 for the 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 a $400 copayment for in-network Medicare-covered outpatient hospital surgery services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $400 copayment for the skin laser treatment.
You have been asked to pay a $173.40 copayment for the skin laser treatment. The skin laser treatment 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 reduce the copayment for the skin laser treatment provided on December 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 30, 2019.
You asked the Plan to waive the copayment for an ultrasound. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for basic imaging services. You have been asked to pay a $20 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 August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) and surgical extractions (D7210) to be provided by an oral surgeon.
You asked the Plan to pre-approve the dental services. You say that bacteria from under your teeth may get into your bloodstream. You also say that it could affect your heart. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist.
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, dental services must be provided by an participating general dentist in order to be covered. Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310) and surgical extractions (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forophthalmologic testing (92134) provided October 4, 2019.You asked the Plan to waive the copayment forthe vision services. You say that you had Vitrectomy surgery and this was a post-op visit and the tests and follow up visits should be covered under the initial cost of the surgery.The Plan denied your request. The Plansays the claim was processed with the correct copayment as diagnostic testing would not be covered under the global billing period following Vitrectomy surgery.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 for each Medicare covered exam, diagnosis and treatment for diseases and conditions of the eye.You have been asked to pay $15for the vision services. The vision services fall within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forophthalmologic testing (92134) provided October 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay at the facility from September 29, 2019 to October 1, 2019.
You asked the Plan to waive the copayment for an observation stay. You say that you should only owe a $90 copayment for emergency room 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 $300 copayment for observation services. The medical records show that you had an observation stay from September 29, 2019 to October 1, 2019. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for an observation stay. An observation stay falls within the outpatient hospital 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 observation stay at the facility from September 29, 2019 to October 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 14,
2019.
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 records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were to be performed. 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 drug testing
services provided to the enrollee on August 14, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea Per Oral Endoscopic Myotomy (POEM) procedure (43499).You asked the Plan to pre-approvethe POEM procedure. You say that the POEM procedure is medically necessary.The Plan denied your request. The Plan says that the enrollee has not trialed other treatments such as medication, endoscopic balloon dilatation, and endoscopic injection of Botox. According to the plan, POEM is considered investigational.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the POEM procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found multiple studies in medical literature support the use of POEM as a front line treatment for the enrollee's condition. The alternatives cited by the plan, endoscopic balloon dilatation and endoscopic injection of Botox are only indicated for patients who cannot tolerate or refuse definitive surgical treatment. Numerous studies show POEM has benefits over traditional surgical treatments (laparoscopic Heller myotomy) in terms of fewer complications and shorter hospital stays. The best practice advice from the American Gastroenterological Association states "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes."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 POEM procedure have been met.Therefore, we decided that the Plan has to pre-approvea Per Oral Endoscopic Myotomy (POEM) procedure (43499).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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaser surgery provided on October 18, 2019.You asked the Plan to waive the copayment forlaser surgery. You say that you had no idea you would have a $200 bill. You say that this should be covered for your medical condition.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 $200 for each Medicare-covered, in-network ambulatory surgical center visit.You have been asked to pay a $200 copayment for laser surgery. Laser 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 copayment forlaser surgery provided on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants.
You asked the Plan to pre-approve the dental services. You say that the enrollee presented with generalized, moderate to severe bleeding gums. You say that there are deep periodontal pockets present. You also say that without these services, the enrollee's periodontal condition will decline. The Plan denied your request. The Plan says periodontal scaling and root planing is not listed as 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, periodontal scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you need custom molded orthotics for your foot pain.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory drug screening services provided on September 19, 2019.
You asked the Plan to waive the copayment for the laboratory drug screening services. You say that you had no blood work done in September. 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 $35 copayment per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay a $35 copayment for the laboratory drug screening services. The laboratory drug screening services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the claim was for urine drug screening services.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory drug screening services provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery (E1399).
You asked the Plan to pre-approve the backup battery. You say that you need this in case of an emergency where the power goes out. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a backup battery (E1399).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation.
You asked the Plan to provide routine transportation. You say that you need transportation to your appointments. The Plan denied your request. The Plan says routine transportation is not a benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided, on October 28, 2019.You asked the Plan to waive the copayment for the office visit. You say that you had an annual wellness visit and do not know why you were charged a $10 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 in-network primary care physician office visits. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you had medications refilled and discussed body aches with the doctor, in addition to the annual wellness 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 office visit provided on October 28, 2019.