Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on August 19, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care on August 19, 2019. Your EOC states, after you pay your $450 deductible, you pay: days 1-90: $300 copayment per day, up to an out-of-pocket limit of $2,100 for each Medicare-covered stay at a network 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 inpatient hospital care on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from November 15, 2019 through November 18, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 pay for inpatient hospital care. Our physician reviewer found the review has determined that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility after the emergency room evaluation on November 15, 2019. The post-stabilization care services after the emergency room evaluation November 15, 2019 were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee fromNovember 15, 2019 through November 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room (ER) services rendered from October 1, 2019 and October 29, 2019.You asked the Plan to waive the copayments for these services. You say that you disagree with the copayments.The Plan denied your request. The Plan says the copayments were 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 an $80 copayment for in-network ER services. Review of the file shows that you received ER services on October 1, 2019 and October 29, 2019. You have been asked to pay an $80 copayment per date of service for these services, for a total of $160. These services fall within the in-network ER 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 emergency room (ER) services rendered from October 1, 2019 and October 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe dentures provided on December 23, 2019.You asked the Plan to waive the coinsurance forthe dentures. Yousay that you were told this would be covered in full.The Plan denied your request. The Plan says that you are responsible for the cost share 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 50% coinsurance for non-Medicare covered dental services. You have been asked to pay a 50% coinsurance for the dentures. The dentures fall within the non-Medicare covered dental 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 coinsurance forthe dentures provided on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the custom inserts provided on October 16, 2019.You asked the Plan to pay for the custom inserts. You say that you need the orthotics but cannot afford them.The Plan denied your request. The Plan says that the inserts were not for a shoe that is an integral part of a covered brace.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were referred for the custom inserts by a contract provider. The file does not show that the Plan provided notice that the custom inserts would not be covered. Under Medicare rules, this means the custom inserts are considered approved by the Plan.Therefore, we decided that the Plan has to pay for the custom inserts provided on October 16, 2019.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral medications and eye drops provided during an outpatient hospital stay from December 5, 2019 to December 6, 2019.
You asked the Plan to pay for the oral medications and eye drops. You say that you feel that this charge should be waived because you were not informed that it would not be covered and were not allowed to bring your own medications. The Plan denied your request. The Plan says you received self-administrable medications while in the outpatient setting. Medicare Part B does not allow coverage for these drugs in this setting. You can request reimbursement from your Part D drug plan for these charges.
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 pay for the oral medications and eye drops provided during an outpatient hospital stay from December 5, 2019 to December 6, 2019.
Benefits for the oral medications and eye drops 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist services rendered on December 16, 2019.You asked the Plan to waive the copayment forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment 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 $50 copayment for each specialist visit for Medicare-covered benefits. Review of the file shows that you received allergy and immunology services on December 16, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the specialist visit for Medicare-covered benefits 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 forthe specialist services rendered on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe wig purchased on November 19, 2019.You asked the Plan to reimburse you forthe wig. You say that you need this wig to maintain a sense of normalcy in your practice.The Plan denied your request. The Plan says wigs are not covered by Medicare or the Plan.Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig.Therefore, we decided that the Plan does not have to reimburse you forthe wig purchased on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for multiple medical services provided from April 11, 2017 to March 21, 2019 by the providing facility.You asked the Plan to waive the copayment for the multiple medical services. You say that the enrollee should not be responsible for the copayments.The Plan denied your request. The Plan says based on Medicare billing criteria, the claims were billed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for each covered lab service based off the 2017 EOC, a $80 copayment for emergency care, a $295 copayment for outpatient hospital services, a $10 copayment for each covered lab service,and 20% coinsurance for Medicare Part B prescription drugs based off the 2018 EOC, a $90 copayment for emergency care, a $345 copayment per day for days 1-5 for inpatient hospital care, and 20% coinsurance for Medicare Part B prescription drugs based off the 2019 EOC. The enrollee has been asked to pay $2,666.59 for the multiple medical services. $60 (lab service copays) + 6.14 + 3.86 + 170 (emergency room copays) + 295 + 108 (20% coinsurance for Medicare Part B prescription drugs) + 2.023.59 (inpatient hospital stays) = $2,666.56. 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 for multiple medical services provided from April 11, 2017 to March 21, 2019 by the providing facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each (A4351) provided to the enrollee.
You asked the Plan to waive the coinsurance for the catheter. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each (A4351). The claims assessed a 20% coinsurance of $72.36 for catheter supplies each for a total member responsibility of $144.72. 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 intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each (A4351) provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from October 1, 2019 through October 31, 2019.
You asked the Plan to waive the copayment for the SNF services. You say that The Plan denied your request. The Plan says cost-sharing is a contractual agreement of the plan and cannot be waived.
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 $160 copayment for each day for days 21 to 54 of SNF care. You have been asked to pay a $756.06 copayment for the SNF services. The SNF services falls within the days 21 to 54 of SNF care benefit category. You were in a SNF for 30 days. The copayment should have been for $1,600. However, the Plan only charged a copayment for $756.06, which brought you to the out-of-pocket maximum. 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 skilled nursing facility (SNF) services provided from October 1, 2019 through October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on October 31, 2017 through November 2, 2017 provided by an in-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2017 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on October 31, 2017 and discharged on November 2, 2017. You were asked to pay a $250 copayment per day from October 31, 2017 through November 1, 2017, days 1-2 of your inpatient hospital care. You were discharged on November 2, 2017 and there was no copayment charge for the day of discharge. Per your contract there is a $295 copayment per day required for days 1-6 for in-network inpatient hospital care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care on October 31, 2017 through November 2, 2017 provided by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on August 28, 2019. You asked the Plan to pay for the hearing aids. You say that you purchased hearing aids which was recommended by your doctor. You paid $4085 with your credit card and would like reimbursement of $700. The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network provider. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when received by a participating provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 16, 2019
through November 21, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review has determined that the record showed that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from November 16, 2019 through November 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the diagnostic colonoscopy and endoscopy provided on November 8, 2019 and November 14, 2019.
You asked the Plan to waive the copayments for the diagnostic colonoscopy and endoscopy. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a diagnostic colonoscopy and an endoscopy procedure on the dates of service at issue in this appeal. The Plan says the correct cost share has applied per your contract with the Plan.
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 $395 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a diagnostic colonoscopy on November 8, 2019 and an Endoscopy on November 14, 2019 provided at an ambulatory surgical center. You have been asked to pay a $395 copayment for each outpatient surgical procedure. The diagnostic colonoscopy and endoscopy fall within the Outpatient surgery benefit category. This means that you have been asked to pay the correct amounts 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 diagnostic colonoscopy and endoscopy provided on November 8, 2019 and November 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on September 16, 2019.
You asked the Plan to pay for the paramedic intercept services. You say that the service was medically necessary so the claim should be paid. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on September 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that the ambulance was called for what appeared to be a heart attack. You stated that this was not the case and you declined transportation. You say that the charge is excessive and that the Plan should cover the expense.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 18, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.