Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a SNF stay. We decided that the Plan does 
not have to reduce the cost-sharing charges for a SNF stay to the amount you requested.  
 
You asked the Plan to reduce the cost-sharing charges for a SNF stay. You say that you were not told that your 
rehabilitation time had expired. The Plan says that the claims were processed correctly and you are being 
charged the correct amount. 
 
We decided that the Plan has to reduce the cost-sharing charges for a SNF stay from $500 to $400.  
 
You had a SNF stay from May 7, 2021, to May 31, 2021. You cannot be charged for the day you are 
discharged. Therefore, we decided that the Plan has to reduce the cost-sharing charges for a SNF stay from 
$500 to $400.  
 
We also decided that the Plan does not have to reduce the cost-sharing charges for a SNF stay to the 
amount you requested.  
 
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 
copayment for days 1-20 and a $100 copayment for days 21-100 for a SNF stay.  
 
You had a SNF stay from May 7, 2021, to May 31, 2021. You are not being charged a copayment for days 1-20 
(May 7, 2021, to May 26, 2021). You are responsible to pay a copayment for days 21-24 (May 27, 2021, to 
May 30, 2021). The total amount you owe is: $100 (copayment) x 4 (SNF days) = $400.  
 
Therefore, we decided that the Plan does not have waive the $400 copayment for a SNF stay.  
 
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the eye exam you had on July 15, 2021. 
 
You asked the Plan to waive the copayment for the eye exam. You say that this was a diabetic eye exam so 
there should be no copayment. The Plan denied your request. The Plan says that you were charged this 
copayment correctly because this was billed as an office visit. 
 
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 enrollees pay a $0 copayment for diabetic eye exams and a $30 copayment for 
vision care specialist visits.  
 
The Plan says you must pay a $30 copayment for the eye exam. We do not find the Plan's argument persuasive.  
Your Evidence of Coverage says that you pay a $0 copayment for diabetic eye exams.  We understand that this 
provider did not bill the correct 'diabetic eye exam' procedure code.  However, the only diagnosis on this claim 
was diabetes, so we can only conclude that this visit was a diabetic eye exam.  The Plan failed to do any fact-
finding regarding this service.  They did not even attempt to get medical records from this date of service to 
confirm the type of exam you actually had.  Based on the diagnosis billing, you were clearly seen solely for eye 
care related to diabetes.  This is a covered service with a $0 copayment in your Evidence of Coverage.  
Therefore, we decided that the Plan has to waive the copayment for the eye exam you had on July 15, 2021.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on November 11, 2020.
You asked the Plan to pay for the wound care services. You say that the services were medically necessary and urgent. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization or referral from a contracted provider. The Plan says the services were not urgent or emergent. dicare 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 had network providers available who could have provided 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 wound care services provided on November 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on July 23, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a colonoscopy screening and you should not owe a copayment. 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received a colonoscopy at an outpatient hospital facility on July 23, 2021, due to chronic diarrhea. Therefore, the colonoscopy is considered diagnostic, not preventative and you are responsible to pay the $400 copayment. 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 for a colonoscopy provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services provided from February 1, 2018, to February 28, 2018.
You asked the Plan to waive the coinsurance for dialysis services. You say that you received the bill almost four years later and cannot afford 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 20% coinsurance for dialysis services. You received dialysis services from February 1, 2018, to February 28, 2018. Therefore, you are responsible to pay your share of the cost-sharing charges.
The total allowed amount is $5,129.52 and 20% of that is $1,025.88. You have been asked to pay the total coinsurance amount of $1,025.88 for dialysis services. Dialysis services fall within the services to treat kidney disease and conditions 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 dialysis services provided from February 1, 2018, to February 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on May 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 had network providers available who could have provided 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 subsequent nursing facility care (99309) provided on May 18, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on December 10, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you have government insurance and as a taxpayer, you should not have a copayment when you call 911. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment for ambulance services. 

You have been asked to pay a $225 copayment for the ambulance services. 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 ambulance services you received on December 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound (93922) provided on June 29, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound (93922). You say that the procedure could not be 
performed. The Plan denied your request. The Plan says the copayment applied was 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 a $160 
copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a 
physician's office or at a free-standing facility (such as a radiology center or medical clinic).  
 
The medical records received show that the service was performed. You have been asked to pay $86.91 for an 
ultrasound, which is less than your $160 copayment. An ultrasound 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 ultrasound (93922) provided on June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on February 04, 2021 and March 11, 2021.
You asked the Plan to pay for the dental services. You say that you were led to believe that these services would be covered. You say that the Plan should pay for the charges for the two dates billed. The Plan denied your request. The Plan says out-of-network dental services are 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on February 04, 2021 and March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, arthrocentesis, and triamcinolone acetonide injection provided on October 29, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit, arthrocentesis, and triamcinolone acetonide injection. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit, arthrocentesis, and triamcinolone acetonide injection provided on October 29, 2020, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoscopic spinal decompression services.
You asked the Plan to pre-approve the requested services. You say that you are having back pain and cannot function. The Plan denied your request. The Plan says the procedure is considered investigational at this time.
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 the requested services. Our physician reviewer found that endoscopic spinal decompression surgery remains experimental. More research is needed to show safety and efficacy. An open surgery remains the standard of care. Therefore, the requested services are 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic spinal decompression services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoe lift for the enrollee.
You asked the Plan to pre-approve a shot lift. You say that a shoe lift is medically necessary as one of the enrollee's legs is shorter than the other. The Plan denied your request. The Plan says this item is 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. The 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 a shoe lift for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy (PT) visits you had on June 5, 2021, and June 7, 2021.
You asked the Plan to waive the copayments for the PT visits. You say that you have never had to pay a copayment before and you thought this was covered in full. The Plan denied your request. The Plan says you were charged these copayments 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 $15 copayment per visit for physical therapy services. You have been asked to pay a $15 copayment per visit for the PT visits. These copayments apply regardless of what you may have paid in the past. 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 physical therapy (PT) visits you had on June 5, 2021, and June 7, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra. 
 
You asked the Plan to pre-approve Xiidra. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says this drug is not covered under your medical benefit. 
 
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 pre-approve Xiidra.  
Benefits for Xiidra may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on June 25, 2021.

You asked the Plan to pay for the limited oral evaluation and intraoral x-ray. You say that you only agreed to the exam and teeth cleaning which is covered by insurance, and the $30 x-ray you would have to pay for. You say that you should have been informed you would not be able to get your teeth cleaned and you should only owe $30. The Plan denied your request. The Plan says the services are not a covered benefit.

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 limited oral evaluation and intraoral x-ray provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from April 12, 2021, to April 17, 2021.
You asked the Plan to pay for the inpatient services. You say that the enrollee's care was medically justified as inpatient. The Plan denied your request. The Plan says the conditions did not qualify for reporting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services with primary diagnosis code A41.9, defined as sepsis, unspecified organism; and secondary diagnosis code R65.20, defined as severe sepsis without septic shock. 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 inpatient services. Our physician reviewer found that the enrollee was admitted for inpatient services for pneumonitis due to inhalation of food and vomit. From the information that was received, documentation was inconsistent regarding a diagnosis of sepsis. Even though sepsis is documented in the history and physical report and discharge summary, supporting medical record documentation was not found within the record. Although the enrollee had a blood pressure of 93/38 and altered mental status are noted upon presentation, these values promptly improved with treatment in the emergency department. In addition, the enrollee's Platelets, total bilirubin, glucose, and lactic acid remained within normal limits through the hospital stay. The review has determined that the billed conditions were not supported in the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from April 12, 2021, to April 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an outpatient hospital facility on May 27, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that it was not explained to you that you would be responsible for this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment for outpatient surgery. The medical records show that this diagnostic colonoscopy was ordered because you were suffering from painful defecation and abdominal pain in the right lower quadrant.
You had polyps removed during this procedure. You have been asked to pay a $300 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient surgery 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 diagnostic colonoscopy you had at an outpatient hospital facility on May 27, 2021.