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

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 6, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that the polyp was not sent for examination. You say that you should not be charged the 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 as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for Medicare-covered outpatient surgery at an in-network ambulatory surgical center. You have been asked to pay a $300 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. 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 September 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Medicare Part B injections and their administrations provided from June 20, 2019 and July 18, 2019.You asked the Plan to waive the cost share forthe Medicare Part B injections and their administrations. You say that you were not told that each treatment would cost $400. You say you will not pay this bill because you live on Social Security. 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 20% of the total cost for other Medicare-covered Part B drugs and a $50 copayment for Medicare-covered specialist services. You have been asked to pay a total cost share amount of $867.03 for the Medicare Part B injections and their administrations. The Medicare Part B injections fall within the "Medicare Part B prescription drugs" benefit category. The administrations fall 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 cost share forthe Medicare Part B injections and their administrations provided from June 20, 2019 and July 18, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 1, 2019 to August 8, 2019 by the out of network provider.
You asked the Plan to pay for the outpatient mental health services. You say that the services should be covered. The Plan denied your request. The Plan says the provider is not contracted with the health plan.
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 medical services provided on August 1, 2019 to August 8, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe outpatient hospital surgeries, the emergency room visit, or the specialist office visit provided from May 14, 2019 to July 11, 2019.You asked the Plan to waive the copayments forthe outpatient hospital surgeries, the emergency room visit, and the specialist office visit. You say that if the initial procedure had been done correctly, the following services would not have been necessary.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for Medicare-covered outpatient surgery at an in-network outpatient hospital, a $90 copayment, up to a maximum, for emergency care, and a $30 copayment for in-network specialist services. The enrollee has been asked to pay a total copayment amount of $563.96 for the outpatient hospital surgeries, the emergency room visit, and the specialist office visit. The outpatient hospital surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The emergency room visit falls within the "Emergency care" benefit category. The specialist office visit falls within "Physician/Practitioner services, including doctor's office visits" 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 copayments forthe outpatient hospital surgeries, theemergency room visit, or thespecialist office visit provided from May 14, 2019 to July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the vision care office visits provided from September 13, 2019 to September 17, 2019.You asked the Plan to waive the deductible forvision care office visits. You say that you have very limited finances and would like the bill to be covered/paid.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible that applies towards each in-network Medicare-covered exam to diagnose and treat diseases or conditions of the eye. The vision care office visits you asked the Plan to waive the deductible for falls within the "Vision care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards in-network vision care office visits. The allowed amount of the visit on September 13, 2019 is $26.86. Therefore, $26.86 is applied to the deductible. The allowed amount of the visit on September 17, 2019 is $82.28. Therefore, $82.28 is applied to the deductible.This cost sharing is a contractual obligation that had not been met at the time vision care office visits were received on September 13, 2019 to September 17, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe vision care office visits provided from September 13, 2019 to September 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulance service provided on August 26, 2019 by out of network provider.You asked the Plan to pay foran ambulance service. You say that the enrollee could not be safely transported any other way.The Plan denied your request. The Plan says no prior authorization was 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 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 foran ambulance service provided on August 26, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee has medical needs that require IRF services. The Plan denied your request. The Plan says the enrollee could receive care in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional physical and occupational therapy but the patient does not require or appear to be able to tolerate this therapy on an intensive rehabilitation facility therapy program level in an IRF. 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of soft tissue neck provided on August 15, 2019.
You asked the Plan to pay for the CT of soft tissue neck. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the CT of soft tissue neck provided on August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Calcitriol 0.5 mcg capsule.You asked the Planto pre-approveCalcitriol 0.5 mcg capsule. You say that the medication is necessary.The Plandenied your request. The Plansays the drug is bundled with the ESRD payment and is not separately payable.The Plan follows Medicare rules. Medicare rules say that all drugs and biologicals used for the treatment of End Stage Renal Disease (ESRD) are included in the ESRD payment and are notseparately paid as of January1, 2011.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Calcitriol 0.5 mcg capsulehave not been met. Specifically, this drug is considered to be included in the ESRD payment and is notseparately payable. The Plan has agreed that this will be covered for the enrollee under Part B, but it will be part of the ESRD payment. Therefore, we decided that the Plan does not have to pre-approveCalcitriol 0.5 mcg capsule.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on January 28, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, wedecided that the Plan does not have to pay fora shoulder-hand-wrist orthosis (L3960) provided to the enrollee on January 28, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay for office visit services provided to the enrollee on January 18, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe provider is not in-network, and there was no 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-approvedcare.The rendering 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 Plandoes not haveto pay foroffice visit services provided to the enrollee on January 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided from June 5, 2019 to August 24, 2019.
You asked the Plan to pay for diabetic supplies. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the delivery ticket and proof of delivery documents submitted do not corroborate the specific supplies billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier must corroborate the documentation in the medical record. The supplier must furnish sufficient information to the Plan to determine whether payment is due. We looked at the file and Medicare rules. The delivery ticket submitted is not signed by the enrollee and does not include a shipping carrier's tracking number to support delivery, and the proof of delivery submitted does not include an order number or details to corroborate the delivery ticket submitted. Therefore, the documentation submitted does not support payment of the claim as billed. Based on this information, we decided that Medicare rules for coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided from June 5, 2019 to August 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from August 13, 2019 to August 16, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you do not agree with the copayment because you say you were seen for less than 20 minutes. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say aplan 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 $325 copayment per day for days 1-5, per admission. You have been asked to pay a $325 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The medical record shows you received services while admitted as an inpatient.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 inpatient hospital stay provided from August 13, 2019 to August 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services.You asked the Plan to waive the copayment forthe ambulanceservices. You say that you are unable to pay this amount at this time and want to make sure this is not covered by the plan.The Plan denied your request. The Plan says you were charged this cost sharing 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 $215 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $215 for these 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 forthe ambulance services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forphysical therapy provided from May 15, 2019 through June 25, 2019.You asked the Plan to waive the copayments forphysical therapy. You say that you received a letter of approval that did not mention any amount due. You say that you should not be responsible.The Plan denied your request. The Plan says the copayments 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 $30 copayment for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits.You have been asked to pay a total of $360 for physical therapy. ($30/visit x 12 visits = $360). Physical therapy falls 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 forphysical therapy provided from May 15, 2019 through June 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided
on September 3, 2019.
You asked the Plan to pay for the 2D oral or facial photographic image. You say that you had 2 fillings done.
You say that the Plan covered none of the cost you feel the Plan should cover according to the book. The Plan
denied your request. The Plan says the 2D oral or facial photographic image 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, the 2D oral or facial photographic
image is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the 2D oral or facial photographic image (D0350) provided on September 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided on August 8, 2019 and August 13, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were not aware you would have to pay $40 for each visit. You say you would not have gone to therapy if you had known it was not covered. 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 $40 copayment for in-network Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. You have been asked to pay a $40 copayment for each of the physical therapy visits. 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 on August 8, 2019 and August 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from August 13, 2019 to
October 3, 2019.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider,
which requires prior authorization from the p
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 and the referring provider in this case are not network providers with the Plan. The Plan
did not pre-approve the 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 physical therapy services provided from
August 13, 2019 to October 3, 2019.