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

We decided that the Plan does not have to waive the coinsurance for hysteroscopies provided on October 1, 2019 and November 15, 2019.You asked the Plan to waive the coinsurance for hysteroscopies. You say that you disagree with the charges and would have stayed overnight if you knew that you would owe 20% coinsurance.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 outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received hysteroscopies from October 1, 2019 to November 15, 2019. Hysteroscopies are considered outpatient surgical procedures. Therefore, you are responsible to pay the total amount of $2,157.94, which is less than the 20% coinsurance amount. You have been asked to pay $2,157.94 coinsurance for hysteroscopies. Hysteroscopies fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 hysteroscopies provided on October 1, 2019 and November 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided August 11, 2019 to
August 13, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you request reconsideration of the
denial of this claim and approve the admission for acute inpatient reimbursement. The Plan denied your
request. The Plan says the information provided does not warrant an inpatient level of care and therefore is not
considered 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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the medical records provided indicate that the admitting physician expected the
enrollee's admission to span two midnights. Care provided to the enrollee was observation level. There were no
advance interventions or complex medical conditions. He had stable vital signs and no complaints at the time
of admission. Inpatient services were not supported by the documentation.
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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided August 11, 2019 to August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The 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 December 3, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing test rendered on November 19, 2019.You asked the Plan to waive the copayment for these services. You say that you didn't want nor need the hearing test and should have no copayment.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 $45 copayment per visit for basic hearing evaluations. The file shows that you received a hearing test on November 19, 2019. Per your contract with the Plan, there is a $45 copayment per visit for basic hearing evaluations. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $43.02. Given that the allowed amount was less than the $45 copayment, you have been asked to pay $43.02 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the hearing test rendered on November 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 9, 2020.You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the claim processed according to your 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). Your contract with the Plan clearly says that you must pay a $250 copayment for each Medicare-covered ground ambulance transport. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the each Medicare-covered ground ambulance transport 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 ambulance transport provided on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS routine disposable supplies (A0382) ambulance waiting time, half hour increments (A0420) unlisted ambulance service (A0999) provided August 14, 2019.
You asked the Plan to pay for the ambulance services. You say that you have billed the other party as originally suggested however, they denied. You are appealing with the denial and request reimbursement for this claim. The Plan denied your request. The Plan says payment for these items is included in the ambulance services fee schedule.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Medicare does not allow for separate billing of these services and supplies. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for BLS routine disposable supplies (A0382) ambulance waiting time, half hour increments (A0420) unlisted ambulance service (A0999) provided August 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ambulance ride provided on November 1, 2019.You asked the Plan to waive the copayment forthe ambulance ride. You say that you cannot afford 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, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 forthe ambulance ride provided on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe delivery charges for the lift chair provided on September 6, 2019 or pay for the therapy system provided on October 28, 2019.You asked the Plan to pay forthe delivery charges for the lift chair and pay for the Ossur Cold Rush Therapy system. You say that you were told these items would be covered at 80%.The Plan denied your request. The Plan says that these services are not covered.The Plan must follow Medicare rules. Medicare rules say that separate delivery and services charges for oxygen or durable medical equipment are only covered in rare and unusual circumstances when the delivery is not typical of the particular supplier's operation. Medicare rules also say that a fluid circulating cold pad with pump will be denied as not reasonable and necessary.Therefore, we decided that the Plan does not have to pay forthe delivery charges for the lift chair provided on September 6, 2019 and pay for the therapy system provided on October 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for parathyroid surgery (60500) provided on October 17, 2019 to October 18, 2019.You asked the Plan to waive the copayment for parathyroid surgery. You say that you were not informed of this copayment.The Plan denied your request. The Plan says the copayment applied to the service 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 Medicare-covered surgery or other services provided to you at an outpatient hospital. You have been asked to pay a $75 copayment for parathyroid surgery, which was a Medicare-covered surgery provided to you at an outpatient 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 parathyroid surgery (60500) provided on October 17, 2019 to October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wig received on April 22, 2019.You asked the Plan to pre-approve the wig. You say that this should be paid for.The Plan denied your request. The Plan says this is not a covered benefit.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. Your plan also specifically does not cover wigs under any condition or circumstance.Therefore, we decided that the Plan does not have to pre-approve a wig received on April 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the scooter, hybrid platform lift, and walker holder purchased on October 3, 2019.You asked the Plan to reimburse you for the scooter, hybrid platform lift, and walker holder. You say you cannot walk and needed the equipment.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to reimburse you 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 item sat issue in this appeal. The Plan did not pre-approve the item sat issue. We found no exception that would require the Plan to reimburse you for these items.Therefore, we decided that the Plan does not have to reimburse you for the scooter, hybrid platform lift, and walker holder purchased on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 24, 2019.
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says that the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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
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 laboratory testing provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on December 9, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services that you provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the processing fee of a gym membership.
You asked the Plan to pay for a gym membership processing fee. You say that this should be paid. The Plan denied your request. The Plan says this fee is not covered under your Plan.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers monthly cost of a single-person gym membership, but does not cover initiation or registration fees, prorated fees, annual fees, account freeze fees, maintenance fees or any miscellaneous fees. The Plan's rules for coverage of gym benefits have not been met because the fee at issue is not the monthly membership cost. The Plan contract states that it does not cover these fees. Therefore, we decided that the Plan does not have to pay for the processing fee of a gym membership.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora colonoscopy provided on October 18, 2019.You asked the Plan to waive the copayment fora colonoscopy. You say that you believe that the colonoscopy should be considered preventative even though you had polyps removed.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 $325 copayment for outpatient hospital facility services.You had polyps removedduring a colonoscopy on October 18, 2019. Therefore, you are responsible to pay the $325 copayment.  You have been asked to pay a $325 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.You asked the Plan to pre-approve the wheelchair. You say that the wheelchair has the potential to increase the enrollee's independence both at home and in the community.The Plan denied your request. The Plan says the safety concerns are not fully addressed.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee is unable to follow single-step commands, and does not demonstrate the ability to safely navigate a power wheelchair. The enrollee lacks safety awareness and insight regarding his abilities, due to decreased cognition. The enrollee cannot safely operate a power wheelchair independently per the PT note. There is no documentation that the enrollee's personal mobility deficit impairs participation in MRADLs. The enrollee is currently using a manual wheelchair which seems to be a safer option.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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the semi-electric hospital bed provided on July 26, 2019 to September 26, 2019by an out of network provider.You asked the Plan to pay for the semi-electric hospital bed. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the itemat issue in this appeal. The Plan did not pre-approve the it emat issue. We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay for the semi-electric hospital bed provided on July 26, 2019 to September 26, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the bladder test provided to the enrollee on November 22,
2019.
You asked the Plan to pay for the test. You say that the bladder test is a non-invasive urine-based and
laboratory-developed based on a bladder cancer molecular signature comprisingthe quantitative measurementof
5mRNA biomarkers clinically associated with urothelial cancer: CDC2, HOXA13,MDX, IGFBP5, and
CXCR2. The Plan denied your request. The Plan says Medicare says tests with no relation to a medical
diagnosis of disease for the health of the patient are not a benefit.
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 pay for the test. Our reviewer says that the services
at issue in this case were not medically reasonable or necessary. Our physician reviewer found because
Cxbladder is a Laboratory Developed Test (LDT), The provider has not been cleared or approved by the US Food
and Drug Administration (FDA). The review has determined that the requested bladder urine test system is
not medically reasonable and necessary.
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 test have not been met. Therefore, we decided that the Plan does not have to
pay for the bladder test provided to the enrollee on November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on November 14, 2019.
You asked the Plan to waive the copayment for an X-ray. You say that you could not get the X-ray done on the same day and had to return. 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 X-rays provided in an outpatient hospital facility. You have been asked to pay a $50 copayment for an X-ray. An X-ray 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 an X-ray provided on November 14, 2019.