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

We decided that the Plan has to pay for the acute inpatient hospital care provided March 7, 2019 to March 10,
2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that you are requesting a
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the claim
was initially paid but placed through financial recovery for a medical record review. Additionally, the Plan did
not render a decision within the allotted timeframe.
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 the 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 that the enrollee was transferred from another facility to the Emergency Department
(ED) on March 7, 2019 for the treatment of Diabetic Ketoacidosis. She required treatment with intravenous
fluids, insulin and bicarbonate. She also had heme positive emesis and required treatment with intravenous
proton-pump inhibitors. The enrollee was then admitted. Her condition stabilized and improved, and she was
transitioned to an insulin regimen. Her electrolytes normalized. She was discharged home on March 10, 2019
with outpatient follow-up. 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 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 the acute inpatient hospital care have been met. Therefore, we decided that the
Plan has to pay for the acute inpatient hospital care provided March 7, 2019 to March 10, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 6, 2019 to August 8, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you were told by the receptionist that the stay was fully covered. 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 $310 copayment per day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from August 6, 2019 to August 8, 2019. Therefore, you are responsible to pay a $310 copayment for days 1-2 (August 6, 2019 to August 7, 2019). $310 (copayment) x 2 (inpatient days) = $620. You have been asked to pay the total copayment amount of $620 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 for an inpatient hospital stay from August 6, 2019 to August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on March 5, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because this was a pre-operative visit.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 $50 copayment for each specialist visit.You had a specialist visit on March 5, 2020. Pre-operative visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 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 fora specialist visit provided on March 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nasal endoscopy provided on December
18, 2019.
You asked the Plan to waive the copayment for the nasal endoscopy. You say that this wasn't surgery. You say
that you were informed the claim was paid in full. 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 $350
copayment for Medicare-covered in-network outpatient surgery services furnished in a physician's office,
certified ambulatory surgical center, hospital outpatient department, or any other location.
You have been asked to pay $262.03, which is less than the standard $350 copayment for the nasal endoscopy.
The nasal endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" benefit category. The nasal endoscopy is considered 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 nasal endoscopy provided on December 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the SNF stay provided from February 28,
2019 to April 12, 2019.
You asked the Plan to waive the copayments for the SNF stay. You say that you were granted and won an
appeal to continue care and should not have to pay for extended services. 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 $0 per
day, days 1-20 and a $172 per day, days 21-100 for each in-network SNF stay.
You have been asked to pay a $3,657.24 for the SNF stay. The SNF stay falls within the "Skilled nursing
facility (SNF) care" benefit category. See chart below. 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 SNF stay provided from February 28, 2019 to April 12,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant supported porcelain crown, tooth 31 (D6065) provided March 10, 2020.
You asked the Plan to pay for the dental services. You say that the services rendered was for an implant supported porcelain crown coded as D6065. But you request the service be covered up to the covered amount that would have been granted for a crown on a tooth supported structure coded as D2750. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant supported porcelain crown, tooth 31 (D6065) provided March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the respiratory test provided on March 20, 2020.
You asked the Plan to waive the copayment for the respiratory test. You say that you should not be responsible for the copayment because the service is a part of your pre-op for your surgery. 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 $20 copayment for Medicare-covered outpatient diagnostic procedures and tests. You have been asked to pay a $20 copayment for the respiratory test. The respiratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a pre-operative service to 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 respiratory test provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on February 24, 2020.
You asked the Plan to waive the copayment for an eye exam. You say that you received screening services and should not owe a copayment because you were not diagnosed with anything. 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 $35 copayment for exams to diagnose and treat diseases of the eye, including an annual glaucoma screening, a $0 copayment for retinopathy screenings for high risk members and for prescription eyewear post-cataract surgery. The medical records show that you received a diagnostic eye exam beyond routine services on February 24, 2020. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for an eye exam. An eye exam falls 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 for an eye exam provided on February 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from February 3, 2020 to February 6, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $195 copayment per day, days 1 to 6 at an in-network inpatient hospital. The enrollee has been asked to pay a $195 copayment for each day of the inpatient hospital stay. ($195 x 3 days = $585). The inpatient hospital stay falls within the "Inpatient hospital care" 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 for the inpatient hospital stay provided from February 3, 2020 to February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on February 14, 2020.
You asked the Plan to waive the copayment for the EKG. You say that you already paid your $45 copayment
for the visit and then received and additional bill. 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 $30
copayment for Medicare-covered non-radiological diagnostic 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 $30 copayment for the EKG.
You have been asked to pay a $18.75 copayment for the EKG. The EKG 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 EKG provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided on January
25, 2020.
You asked the Plan to waive the copayment for an observation stay. You say that you did not feel comfortable
at the hospital and asked to be discharged and 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 $300
copayment for observation services.
The medical records show that you received observation services on January 25, 2020. 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 provided on January 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wig, any type, each (A9282) purchased on March 28, 2019.
You asked the Plan to pay for the wig. You say that you need the wig because you have Alopecia. The Plan
denied your request. The Plan says cosmetic surgery is not a covered benefit according to your plan of benefits.
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 pay for wig, any type, each (A9282) purchased on March 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on
March 20, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the
charges because you have never been charged in the past. The Plan denied your request. The Plan says the
claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for DME and related supplies.
You received DME and related supplies on March 20, 2019. The total allowed amount is $8,553.85 and 20% of
that is $1,710.76.
You have been asked to pay the total coinsurance amount of $1,710.76 for DME and related supplies. DME
and related supplies fall within the DME and related supplies benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for DME and related supplies provided on March 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 3, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says
that the member's primary physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit provided on March 3, 2020 by an
out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Inogen 1GS oxygen delivery device, an extra battery and shipping purchased January 21, 2020 through January 23, 2020 from an out-of-network provider.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Under Medicare guidelines, your request is not a covered benefit because Medicare does not cover purchased oxygen equipment. Further, a backup battery is considered precautionary and Medicare does not provide coverage benefits for precautionary devices. Therefore, we decided that the Plan does not have to pay for Inogen 1GS oxygen delivery device, an
extra battery and shipping purchased January 21, 2020 through January 23, 2020 from an out-of-network provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing panel of 8-14 drug classes provided on June 25, 2019.
You asked the Plan to pay for the definitive drug testing panel. You say that this was ordered by the treating physician and is considered medically necessary for patient management. The Plan denied your request. The Plan says that the documentation does not support that the 8-15 drug classes described by this panel were tested in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code G0481 is supported in the medical record. Specifically, with review of the CPT Codebook definitive drug class listing, we find that the lab results show that at least 8 but no more than 15 drug classes were tested based on the physician order. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing panel have been met. Therefore, we decided that the Plan has to pay for the definitive drug testing panel of 8-14 drug classes provided on June 25, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral exam (D0150) provided March 17, 2020.
You asked the Plan to pay for the dental services. You say that you believe the last time you went to the dentist
was around September 2018. You do not see how you could have exceeded the frequency for visits. The Plan
denied your request. The Plan says this service exceeds the benefit frequency limitation.
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. The health plan contract says
that this service is covered once every 3 years. The records show that payment for this service was September
21, 2018.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
comprehensive oral exam (D0150) provided March 17, 2020.