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

We decided that the Plan does not have to waive the copayment foran emergency department (ED) visit (99285), a comprehensive metabolic panel (80053), an infusion of normal saline solution (J7030), and a measurement of lipase(83690) provided by "the hospital" from September 10, 2019 through September 11, 2019.You asked the Plan to waive the copayment foran ED visit. You say that you were experiencing extreme pain in your back and abdomen. You request payment be made on your behalf as you feel you should not be held responsible for treatment because you were not satisfied.The Plan denied your request. The Plan says emergency services have a $90 copayment.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. You have been asked to pay a $90 copayment for an ED visit. This servicefalls within the emergency 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 foran emergency department (ED) visit (99285), a comprehensive metabolic panel (80053), an infusion of normal saline solution (J7030), and a measurement of lipase (83690) provided by "the hospital" from September 10, 2019 through September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, tomographic (SPECT) (78452), and the coinsurance for an injection of regadenoson (J2785) provided on May 13, 2019.You asked the Plan to waive the copayment fora SPECT and an injection. You say that you don't believe you should be responsible for the cost-share for the MRI that was completed because you were directed to go to that location by yourdoctor.The Plan denied your request. The Plan says outpatient diagnostic tests have a $250 copayment for covered diagnostic radiology services in the outpatient department of a network hospital or facility. These include radiation therapy, PET, CT, SPECT, MRI scans, heart tests called echocardiograms, lab tests, genetic tests, sleep studies and related supplies. The Plan says that Medicare Part B prescription drugs have a 20% coinsurancefor drugs that usually aren't self-administered by the patient andare injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient diagnostic tests that includes a SPECT and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $250 copayment for a SPECT and an$82.24coinsuranceforan injection. These servicesfall within the outpatient diagnostic tests that includes a SPECT and Medicare Part B prescription drugs benefit category. The allowable amount for the injection is $411.20x20% =$82.24. $250+$82.24 = $332.24. 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 formyocardial perfusion imaging, tomographic (SPECT) (78452), and the coinsurance for an injection of regadenoson (J2785) provided on May 13, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe shoulder orthosis provided on August 30, 2019.You asked the Plan to waive the coinsurance forthe DME. You say that you were unaware of the sling being necessary and woke up with the sling after your shoulder surgery.The Plandenied 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 the shoulder orthosis provided on August 30, 2019. You are asked to pay 20% coinsurance for the DME. 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 shoulder orthosis provided on August 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visits provided on April 18, 2019 and April 19, 2019.You asked the Plan to waive the copayment for the ED visits. You say that you are appealing your copayments.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for emergency care.You have been asked to pay a $100 copayment for each ED visit. The totalamount you owe is $200 ($100/visit x 2 visits = $200). The ED visits fall within the "Emergency 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 forthe ED visits provided on April 18, 2019 and April 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonid-Formoterol Fumarate for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has a medical only policy with the plan.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 Plandoes not haveto pre-approveBudesonid-Formoterol Fumarate for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided to the enrollee from July 9, 2019 through July 25, 2019.You asked the Plan to waive the copayment forSNF care. You say that you never received any documents stating what the cost was for your mother's stay.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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). According to the member's benefits, SNFcare is covered with a $0 copayment for each day for days 1 to 20, $125 copayment for each day for days 21 to 40, and $0 copayment for additional Medicare-covered days up to 100 days. The member is responsible for becoming familiar with their benefits and for paying their share of the cost when they get a covered service. From April 27, 2019 to April 29, 2019 the member received 2 days of SNF care, May 02, 2019 to May 16, 2019 the member received 14 days of SNF care, and from July 09, 2019 to July 26, 2019 the member received 17 days of SNF care. for a total of 33 days. For days 1 to 20 the copayment applied was $0; however, for days 21 to 33 the copayment is $125 for each day for a total of $1,625. The benefit period begins when the member is admitted as an inpatient and ends when the member has not been an inpatient for 60 days in a row. The member did not go 60 days without being inpatient which is why the benefit period did not restart. Therefore, the copayment of $1,625 for SNF services rendered on July 09, 2019 to July 26, 2019 is correct. 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 forSNF care provided to the enrollee from July 9, 2019 through July 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from June 12, 2019 to June 13, 2019.You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that self-administered drugs are not covered.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 forthe self-administered drugs provided from June 12, 2019 to June 13, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe frames and lenses provided on September 5, 2019.You asked the Plan to pay forthe frames and lenses. You say that you have always paid your share in the past, yet now is refusing to pay now.  The plan plainly states the plan pays up to $100 every year for eye frames and lens to any provider.The Plan denied your request. The Plan says frames and lenses are not covered under the plan benefits.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. The Plan covers these services when eyewear is only covered post cataract surgery and 1 routine eye exam (including refraction and dilation) a year..We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met.Therefore, we decided that the Plan does not have to pay forthe frames and lenses provided on September 5, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe ultrasounds provided March 27, 2019.You asked the Plan to waive the deductible for the ultrasounds. You say that you were not aware that the provider was out-of-network. You say that you cannot afford the bill.The Plan denied your request. The Plan says the deductible applied correctly.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 your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Out-of-network services are not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 applies to out-of-network services. This cost sharing is a contractual obligation that had not beenmet at the time the ultrasounds werereceived on March 27, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe ultrasounds provided March 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair of an extensor tendon (27664) provided on August 1, 2019.You asked the Plan to pay for the repair of an extensor tendon. You say that the records support the use of this code.The Plan denied your request. The Plan says this code is not supported by the records.The Plan must follow Medicare rules. Medicarerules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code repair, extensor tendon, leg; primary, without graft, each tendon.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 repair of an extensor tendon. Our reviewer says that CPT code 27664 is not supported by themedical record. Our physician reviewer found the documentation states that a secondary extensor repair with a graft was performed. According to CPT rules, there is a more specific code for this procedure.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 repair of an extensor tendon have not been met.Therefore, we decided that the Plan does not have to pay forthe repair of an extensor tendon (27664) provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 19, 2019 by out of network provider.You asked the Plan to pay for podiatry services. You say that you were told by the Plan that this would be covered.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 casesinvolving 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 forthe medical services provided on June 19, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 31, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. 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.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 did not pre-approve the servicesat issue. We found no exception that would require the Plan topay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon January 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.You asked the Plan to pre-approve proton beam therapy. The Plan denied your request. The Plan says this treatment is not known to be more effective than other types of radiation therapy.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 proton beam therapy. Our physician reviewer found that The enrollee agreed to consent to a registry study Notably, registry studies are not clinical trials or studies, and have a much less rigorous development process. A tumor registry does not address a specific scientific question but rather registers the patient's clinical and treatment information into a database for potential analysis in the future. There is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible advantage of this expensive therapy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan does not have to pre-approveproton beam therapy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foran inpatient hospital stays provided by "the medical center" from August 18, 2019 to September 6, 2019.You asked the Plan to waive the copayments forinpatient stays. You say that you were charged double copayments for your hospital care.The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.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 $265 copayment per day for days 1 to 6 and $0 copayment for additional days for inpatient hospital care. The first inpatient stay from August 18, 2019 to August 29, 2019 lasted 11 days, resulting in a copayment amount of $1,590. The second inpatient stay from August 30, 2019 to September 6, 2019 lasted 7 days, resulting in a copayment amount of $1,590. Your total copayment obligation is therefore $3,180.You have been asked to pay $265 copayment per day for days 1 to 6 and $0 copayment for additional days for each inpatient stay. Inpatient stays fall 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 copayments foran inpatient hospital stays provided by "the medical center" from August 18, 2019 to September 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visit provided on September 25, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that this was directly related to your inpatient hospital stay. You say that the copayment should be waived.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 $75 copayment for emergency care.You have been asked to pay a $75 copayment for the ED visit. The ED visit falls within the "Emergency 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 forthe ED visit provided on September 25, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory testingon August 20, 2019.You asked the Plan to waive the copayment forlab test. You say that your Evidence of Coverage say that you pay a copayment if you request lab work, but if it is requested by a doctor the Plan waives the copayment.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $10 copayment for lab test. You have been asked to pay the allowed amount of $4.38, which is less than the $10 copayment for lab test. Lab test 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 forlaboratory testing on August 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee requires minimal assistance with mobility related activities of daily living.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 physician reviewer found that you are at minimal to moderate assist for ambulation, and minimal assist for transfers. The complexity of your 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 your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional physical and occupational therapy, but do not require this 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-approveacute inpatient rehabilitation facility (IRF) admission and services.