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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 4, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the multiple copayment 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 $45 copayment for specialist visits. You have been asked to pay a $45 copayment for a specialist visit. A 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 specialist visit provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hormone pellet insertion provided on August 26, 2019.
You asked the Plan to waive the copayment for the hormone pellet insertion. You say that the same procedure previously had a $40 copayment. You say that you are appealing 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 $275 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital You have been asked to pay a $275 copayment for the hormone pellet insertion. The hormone pellet insertion falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that the hormone pellet insertion was provided by the hospital. 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 hormone pellet insertion provided on August 26, 2019.
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 SNF services. The Plan denied your request. The Plan says that you are unable to benefit from daily skilled therapy with material gains.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 referring provider 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 the medical services provided on March 20, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total electric hospital bed (E0265) with mattress.
You asked the Plan to pre-approve the total electric hospital bed. You say that you are bedridden and your wife is having difficulties taking care of you as she is a cancer survivor. The Plan denied your request. The Plan says the height adjustment feature is a convenience feature and therefore a total electric hospital bed is not a covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve total electric hospital bed (E0265) with mattress.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the ankle fracture repair surgery provided on October 25, 2019.
You asked the Plan to reduce the coinsurance for the ankle fracture repair surgery. You say that you had no choice but to return to the hospital for surgery. You say you did not know the surgery would be processed as out-of-network. 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 40% coinsurance for at an out-of-network outpatient hospital facility. You have been asked to pay $2,104.40 which is 40% of the allowed amount for the ankle fracture repair surgery. The allowed amount is $5,261.01. ($5,261.01 x 40% = $2,104.40). The ankle fracture repair surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the ankle fracture repair surgery is considered an elective surgery and not an emergency. The record also shows the hospital is out-of-network.
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 coinsurance for the ankle fracture repair surgery provided on October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 70 additional round trip transportation.
You asked the Plan to pre-approve additional transportation. You say that you go to therapy 3 times a week and 50 trips will not be enough for you to be able to complete your therapy. The Plan denied your request. The Plan says this request exceeds the transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers additional transportation when routine transportation is covered for up to 50 one-way trips per calendar year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of additional transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve 70 additional round trip transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPAP battery backup.
You asked the Plan to pre-approve CPAP battery backup. You say that you need a CPAP battery backup during times when there is no electricity. The Plan denied your request. The Plan says CPAP battery backup is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered DME. 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. Medicare will not pay separately or make any additional payment for backup equipment. Therefore, we decided that the Plan does not have to pre-approve CPAP battery backup.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the special stain including interpretation and report provided on August 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory service. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 the special stain including interpretation and report provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on August 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
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 the nursing facility care (99309) provided on August 27, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from August 14, 2019 to August 28, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that insurance approved 13 physical therapy visits. You say nothing was mentioned of a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Medicare-covered physical therapy and/or speech and language pathology visits. You have been asked to pay a $35 copayment for each of the physical therapy visits. ($35 x 5 visits = $175). The physical therapy visits fall within the "Outpatient rehabilitation 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 the physical therapy visits provided August 14, 2019 to August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis to be provided by OON provider.
You asked the Plan to pre-approve the knee orthosis (L1851). You say that the orthosis is medically necessary. The Plan denied your request. The Plan says the orthosis is available within the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. We found no exception that would require the Plan to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis to be provided by OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile needles (A4215) provided by Accurate Neuromonitoring on October 16, 2019.
You asked the Plan to pay for sterile needles (A4215). You say that the Plan should pay this claim. The Plan denied your request. The Plan says sterile needles submitted to the DME MAC will be denied as noncovered.
The Medicare Drug Program (Part D) may cover the sterile needles (A4215) you asked the Plan to pay for. Medicare Guidance says some items may not meet the definition of a Medicare benefit or may be statutorily excluded. Therefore, we decided that the Plan does not have to pay for sterile needles (A4215) provided by Accurate Neuromonitoring on October 16, 2019. Please contact the health plan for further information concerning any Medicare Part D items.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided from October 15, 2019 through October 17, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you were transferred from the emergency room to the hospital. You say that you do not owe a copayment for the emergency room visit. 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 $90 copayment for emergency services in an emergency room. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were admitted to outpatient observation. 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 ED visit provided from October 15, 2019 through October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam provided on October 1, 2019.
You asked the Plan to pay for the eye exam. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says they confirmed this visit was a medical visit.
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. We looked at the file and the Plan's rules. Review of the file show that you received a medical eye exam provided on October 1, 2019. Therefore, your supplemental benefit does not apply because this was not a routine eye exam. You are asked to pay a $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk. Therefore, we decided that the Plan does not have to pay for a medical eye exam provided on October 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that an LTACH admission is medically appropriate.The Plan denied your request. The Plan says the enrollee's needs can be met in the current hospital.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 in this case, ongoing care needs include respiratory support with oxygen supplementation, nebulizers, surveillance laboratory studies, indicated transfusions, tube feeding, 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 thisinformation, 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe retinopathy treatment provided on September 27, 2019.You asked the Plan to waive the copayment forthe retinopathy treatment. You say that there has not been a copayment for this procedure before. You say that you didn't know there was going to be a copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such ascopayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $75 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.The enrollee has been asked to pay a $75 copayment for the retinopathy treatment. The retinopathy treatment falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe retinopathy treatment provided on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC). You asked the Plan to pre-approvethese services. You say that you have falls and can't walk.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met.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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not clearly show that you have a mobility limitation. There is no evidence of a mobility limitation that affects your ability to perform mobility-related activities of daily living (MRADLs). There is no detailed upper extremity exam indicating limitations that would not allow you to use a manual wheelchair or walker. There is no home assessment with detailed measurements showing that you could safely use a PWC in the home. The requested PWC is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 2 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe abscess procedure and biopsy provided on October 3, 2019.You asked the Plan to waive the copayment forthe abscess procedure and biopsy. You say that you were not aware that you would be charged for surgery. You say you would like this charge removed. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.Therules 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 outpatient hospital visit. You have been asked to pay a $250 copayment for the abscess procedure and biopsy. The abscess procedure and biopsy fall within the "Outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers" benefit category. The record shows the abscess procedure and biopsy are considered surgical procedures.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 topay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe abscess procedure and biopsy provided on October 3, 2019.