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

We decided that the Plan does not have to waive the copayment for the duplex scan provided on September 6, 2019.

You asked the Plan to waive the copayment for the duplex scan. You say that submitted your bill for review. 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 $100 copayment for each Medicare-covered radiological diagnostic service. 

You have been asked to pay a $100 copayment for the duplex scan. The duplex scan 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 duplex scan provided on September 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe inpatient stay provided from January 14, 2019 through January 21, 2019.You asked the Plan to waive the coinsurance forthe inpatient stay. You say that you were advised your copayment would be $270 for the first 7 days. You say that the bill is more than you can pay.The Plan denied your request. The Plan says the coinsurance 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 45% per stay for each medically necessary out-of-network inpatient stay.You have been asked to pay $5,642.78, which is 45% of the allowed amount for the inpatient stay. The allowed amount is $12,539.53 (45% x $12,539.53 = $5,642.78). The inpatient stay falls within the "Inpatienthospital care" benefit category. The records show that the provider is out-of-network. 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe inpatient stay provided from January 14, 2019 through January 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visit provided on March 16, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that you were informed you could not go to an urgent care facility. You say that you should be reimbursed the extra cost for the emergency roomvisit.The Plan denied your request. The Plan says the copayment applied correctly.The rules saya 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 each emergency room visit.You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the ED. 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 March 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the inpatient hospital stays or the inpatient acute rehab stay provided from September 27, 2019 to October 18, 2019.
You asked the Plan to reduce the copayments for the inpatient hospital stays and the inpatient acute rehab stay. You say that you were transferred between inpatient to rehab. You say you were never discharged and feels that this should have been billed as one continuous stay. 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 $370 copayment per day for days 1-5 for covered hospital care. Thereafter, you pay a $0 copayment for additional Medicare-covered days during your hospital admission. You have been asked to pay a total of $4,810 for the inpatient hospital stays and the inpatient acute rehab stay. The inpatient hospital stays and the inpatient acute rehab stay fall within the "Inpatient hospital care" benefit category. See chart below. Dates of Service
Service
Copayment per Day
Number of Days
Member Liability
September 27, 2019 to October 2, 2019
Inpatient stay
$370
4
$1,480
October 2, 2019 to October 14, 2019
Inpatient rehab stay
$370
5
$1,850
October 14, 2019 to October 18, 2019
Inpatient stay
$370
4
$1,480
Total
$4,810
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 reduce the copayments for the inpatient hospital stays or the inpatient acute rehab stay provided from September 27, 2019 to October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an OxyGo Fit portable oxygen concentrator.
You asked the Plan to pre-approve an OxyGo Fit portable oxygen concentrator. You say that your current OxyGo portable oxygen concentrator is too heavy for you to carry and the OxyGo Fit would enable you to go outside and perform physical activities on your own. The Plan denied your request. The Plan says you have a portable oxygen concentrator and your needs are currently being met.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. We looked at this physician's review, the file, and Medicare rules. The record shows you have a portable oxygen concentrator that meets your in-home needs. Based on this information, we decided that Medicare rules for coverage of an OxyGo Fit portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an OxyGo Fit portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gene analysis and molecular pathology procedure provided on October 17, 2019 by an OON provider.You asked the Plan to pay forthe gene analysis and molecular pathology procedure. You say that the services rendered were medically necessary.The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that 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 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 gene analysis and molecular pathology procedure provided on October 17, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has heel pain. The Plan denied your request. The Plan says these items are not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for the outpatient visit (G0463). You say that at the time of service, you were not aware of the member's insurance. The Plan denied your request. The Plan says the member sought non-emergent services through a non-contracted 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 for the medical services provided on May 3, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 18, 2019 through October 21, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you have been treated for the same thing three different times. 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 $350 per day for days 1-5, each time you are admitted to an acute care hospital. You have been asked to pay a $1,050 copayment for the inpatient stay. ($350/day x 3 days = $1,050). The inpatient 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 the inpatient stay provided from October 18, 2019 through October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for leuprolide provided on October 8, 2019.
You asked the Plan to waive the coinsurance for leuprolide. You say that your copayment should be less. You say that you want to know the difference in cost. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy drugs. You have been asked to pay $269.64, which is 20% of the allowed amount for leuprolide. The allowed amount is $1,348.20 (20% x $1,348.20 = $269.64). Leuprolide falls within the "Medicare Part B prescription drugs" 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 leuprolide provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to payforthe periodontal maintenance provided on October 31, 2019.You asked the Plan to pay forthe periodontal maintenance. You say that you wish to be reimbursed for the amount your dentist would have been reimbursed for a normal cleaning.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.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 fortheperiodontal maintenance provided on October 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided from September 6, 2019 through November 21, 2019.You asked the Plan to waive the copayment forphysical therapy. You say that you were informed physical therapy was under the global period post-surgery. You say that youwere informed youdon't need to pay the copayment.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for in-network outpatient rehabilitation services.You have been asked to pay a $10 copayment for each physical therapy visit. The total amount you owe is $170 ($10/visit x 17 visits = $170). Physical therapy falls within the "Outpatient rehabilitation services" benefit category. There is no provision in the contract which indicates a copayment would be waivedfor servicesperformed as a follow-upto 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 Plandoes not have to waive the copayment forphysical therapy provided from September 6, 2019 through November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.

You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee qualifies for a CGM. The Plan denied your request. The Plan says criteria was not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.

We looked at the file and Medicare rules. The record shows the enrollee is only insulin injecting twice a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit provided on March 11, 2019 by an OON provider.You asked the Plan to pay forthe outpatient office visit. You say that the clinic did not tell you that they did not take your insurance. You also say that you have gone to this provider before.The Plan denied your request. The Plan says these services were rendered by an out-of-network provider.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 item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided thatthe Plan does not have to pay forthe outpatient office visit provided on March 11, 2019 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endodontic therapy provided on November 6, 2019.You asked the Plan to pay forthe endodontic therapy. You say that your plan includes dental and while you were traveling you experienced an emergency tooth problem.The Plandenied your request. The Plan says this service is not covered.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 forthe endodontic therapy provided on November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing forcataract surgeries provided on June 4,2019 and June 11, 2019.You asked the Plan to waive the cost-sharing forcataract surgeries. You say that you are requesting payment of these claims.The Plan denied your request. The Plan says the cost-sharing 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 $345 copayment for each in-network cataract surgery at an ambulatory surgical center. You have only been asked to pay $310 copayment for each cataract surgery, which is less than the $345 applicable copayment amount, resulting in a total copayment obligation of $620.You have been asked to pay $310 for each cataract surgery, which is less than the $345 copayment for cataract surgery provided at an ambulatory surgical center. Cataract surgeries fall 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 cost-sharing forcataract surgeries provided on June 4, 2019 and June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an Exogen Ultrasound Bone Healing System
You asked the Plan to pre-approve a bone growth stimulator (E0760). You say that the enrollee's fracture is not healing. The Plan denied your request. The Plan says that there is no confirmation on the radiological film that the fracture isn't healing.
The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 a bone growth stimulator (E0760). Our physician reviewer found that this enrollee presents status post closed reduction and cephalomedullary nail
fixation of the left subtrochanteric femur fragility fracture on September 6, 2019. Significant comorbidities are documented. Post-operative x-rays on October 15, 2019, November 21, 2019, and December 10, 2019 have documented no significant progressive healing. Medicare criteria support the use of ultrasound bone growth stimulation for no significant fracture healing evidenced between two sets of x-rays, separated by a minimum of 90 days. In this case, there is no evidence of significant fracture healing documented from the date of surgery on September 6, 2019 with three sets of subsequent x-rays over 90 days post-operatively. Therefore, the enrollee meets the requirement for an osteogenesis stimulator. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bone growth stimulator (E0760) have been met. Therefore, we decided that the Plan has to pre-approve an Exogen Ultrasound Bone Healing System
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on October 9, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you should not have to pay for this service.The Plan denied your request. The Plan says that 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 $325 for Medicare-covered ambulance services per day. You have been asked to pay a $325 for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services per day 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 youenrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance transport provided on October 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on December 11, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that the colonoscopy should be 100% covered because the Evidence of Coverage shows that there is no copayment for a colorectal screening.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 $250 copayment for ambulatory surgical center and outpatient hospital visits. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the colonoscopy was performed due to chronic diarrhea. Therefore, the colonoscopy is considered diagnostic in nature.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 colonoscopy provided on December 11, 2019.