Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the wound vac you received from an out-of-network provider on May 12, 2021.
You asked the Plan to reduce the coinsurance for the wound vac. You say that you believe the provider is in-network, so the coinsurance should only be 20%. You also stated that you have returned the item. The Plan denied your request. The Plan says you were charged the out-of-network coinsurance correctly. The Plan confirmed that the provider is not a network provider with the Medicare Advantage plan.
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 40% coinsurance for durable medical equipment obtained from an out-of-network provider. You have been asked to pay 40% coinsurance for the wound vac. The wound vac falls within the durable medical equipment obtained from an out-of-network provider benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. Please note that for rented durable medical equipment such as this, rental is on a per-month basis and is not pro-rated, even if the item is returned
before the month's end. 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 coinsurance for the wound vac you received from an out-of-network provider on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction rendered on August 2, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 one routine eye exam with refraction per year when done for the purpose of prescribing eyewear. We looked at the file and the Plan's rules. The file shows that the refraction was done as part of a medical diagnostic exam and not for the purposes of routine eyewear. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction rendered on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for outpatient surgery provided in an outpatient hospital facility from April 30, 2021, to May 1, 2021.
You asked the Plan to reduce the copayment for the outpatient surgery. You say that you were told that the copayment was only $245. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that phone records from April 16, 2021, show that you were advised prior to the services that the copayment for outpatient surgery was $275.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for outpatient surgery in an outpatient hospital facility.
The enrollee has been asked to pay a $275 copayment for the outpatient surgery. 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 reduce the copayment for outpatient surgery provided in an outpatient hospital facility from April 30, 2021, to May 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit, and the self-administered drugs provided in an outpatient setting from March 24, 2021, to March 25, 2021.
You asked the Plan to pay for the emergency room visit and self-administered drugs. You say that since you were in a room and did not leave, you considered yourself to be admitted. You say that since you were inpatient, your benefit is only 5% of the Medicare approved amount. You also say that you feel you do not owe this money and it should be covered by the plan. The Plan denied your request. The Plan says the claim was processed correctly. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 $65 copayment for emergency care. The rules also 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. You have been asked to pay $65 copayment for the emergency room visit. The emergency room 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. Additionally, self-administered drugs are not covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the emergency room visit, and the self-administered drugs provided in an outpatient setting from March 24, 2021, to March 25, 2021.
Benefits for the self-administered drugs 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 31, 2021, to August 18, 2021.
You asked the Plan to pay for the SNF care. You say that are still in extreme pain. You also say that the continued SNF services are medically necessary. The Plan denied your request. The Plan says the SNF care is provided for up to 100 days per benefit period. The Plan says that the care you received in this case exceeds the 100 days.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from January 6, 2021, to July 30, 2021. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 31, 2021, to August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you had on June 21, 2021.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you were told your cost sharing would only be $20 or $50. You said that had you known the cost, you would not have received this drug. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the Medicare Part B 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 the Prolia injection you had on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the ophthalmology office visit, fluorescein angiography, and Avastin injection you received on April 2, 2021; the ophthalmology office visit, computerized ophthalmic scan, and Avastin injection you received on April 30, 2021; the office visit, computerized ophthalmic scan and Avastin injection you received on June 1, 2021; and the office visit, the computerized ophthalmic scan and Avastin injection you received on July 23, 2021.
You asked the Plan to waive the cost sharing for the ophthalmology visits, fluorescein angiography, the computerized ophthalmic scans, and Avastin injections. You say that you were never told that the different treatments you received during these office visits would be billed separately. You also stated that you were not provided the opportunity to decline treatment. You believe that you should only have one office visit
copayment for each date of service and that should cover all of the services received. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for each of the computerized ophthalmic scans, the allowed amount for these services ($38.14) is less than your copayment obligation, so you are responsible for the full allowed amount for each of those 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 $40 copayment for visits with a specialist, a $90 copayment for diagnostic tests in a doctor's office, and 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $40 copayment for each of the ophthalmology visits, a $90 copayment for the fluorescein angiography, a $38.14 copayment for each of the computerized ophthalmic scans, and 20% coinsurance for each of the Avastin injections. The office visit copayment covers consultation, diagnosis, and treatment by a physician. It does not include any diagnostic testing or drugs that you may receive. This is pointed out in the outpatient diagnostic testing section of the Evidence of Coverage in that it specifically states that there is cost sharing for these tests received in a physician's office. That puts an enrollee on notice that this cost sharing is above and beyond the office visit copayment. These cost sharing amounts are contractual obligations you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the ophthalmology office visit, fluorescein angiography, and Avastin injection you received on April 2, 2021; the ophthalmology office visit, computerized ophthalmic scan, and Avastin injection you received on April 30, 2021; the office visit, computerized ophthalmic scan and Avastin injection you received on June 1, 2021; and the office visit, the computerized ophthalmic scan and Avastin injection you received on July 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram provided on February 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that the services were necessary. 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 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 screening mammogram provided on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays of the knee, hip, and spine you received on May 19, 2021.
You asked the Plan to waive the copayment for the x-rays. You say that you feel as though these x-rays weren't necessary, so you shouldn't have to pay the 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 $60 copayment for x-rays. You have been asked to pay a $60 copayment for the x-rays. This copayment applies regardless of the reason for the x-rays. 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 x-rays of the knee, hip, and spine you received on May 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from March 5, 2020, to March 31, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation does not support of risk for malnutrition or malnutrition.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation is insufficient to support the coding of "at risk for malnutrition or malnutrition". The case file does not contain physician documentation of "at risk for malnutrition" or "malnutrition." 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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from March 5, 2020, to March 31, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for the canalith repositioning therapy service (procedure code 95992) you had on June 11, 2021.
You asked the Plan to waive the copayment for the canalith repositioning therapy service. You say that you were already charged a copayment for physical therapy on this date, and that copayment should include this service. The Plan denied your request. The Plan says that you were charged two separate copayments correctly. The Plan says that this service is considered a specialist service, so separate cost sharing applies.
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 says that you pay a $20 copayment per visit for physical therapy services. If the same service type is performed at the same session, only one copayment will apply.
We looked at your contract with the Plan. We also looked at the bill for these services. According to the bill, you had both a physical therapy visit and a canalith repositioning therapy service. Both services were performed by a physical therapist and both are considered outpatient rehabilitation services. A reasonable enrollee would expect that only one copayment would apply in this case, since all services were performed on the same day by the same provider type (i.e., a physical therapist.) It is not reasonable for the Plan to charge a separate copayment for the canalith repositioning therapy service based on this information. The contract does not spell out that a separate cost sharing amount would apply for this service by a physical therapist. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the canalith repositioning therapy service (procedure code 95992) you had on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with your cardiologist on August 2, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that you were only able to speak to the cardiologist for 25 minutes but then technical issues prevented the visit from continuing. You also stated that you have not been charged for telehealth visits since September of 2020. 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 $35 copayment for specialist visits, including telehealth services. You have been asked to pay a $35 copayment for the telehealth visit. This copayment applies regardless of how long the telehealth visit lasts and regardless of what you may have paid for this service last year. 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 telehealth visit you had with your cardiologist on August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to the x-ray of the spine you had on June 16, 2021.
You asked the Plan to waive the deductible applied to the x-ray. You say that you would like this charge removed because this x-ray was not necessary. The Plan denied your request. The Plan says you were assessed this deductible correctly. The Plan says you had not met your deductible at the time of these services.
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 there is a $750 deductible which applies to basic and advanced diagnostic imaging. The x-ray falls within the basic diagnostic imaging benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to basic diagnostic imaging. This cost sharing applies regardless of the reason for the service. This cost sharing is a contractual obligation that had not been met at the time the x-ray was received on June 16, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied to the x-ray of the spine you had on June 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the diagnostic mammogram, digital breast tomosynthesis, and breast ultrasound you had at an outpatient hospital facility on July 14, 2021.
You asked the Plan to waive the cost sharing for the diagnostic mammogram, digital breast tomosynthesis, and breast ultrasound. You say that you were told there would be no charge for these services. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that it covered, in full, the screening mammogram you had on July 8, 2021. The Plan says that because the allowed amounts for the diagnostic mammogram ($85.89), the breast tomosynthesis ($23.99) and the breast ultrasound ($78.61) are less than your copayment obligations for each service, you are responsible for the full allowed amounts for each.
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 x-rays in the outpatient department of a hospital or facility and a $230 copayment for other diagnostic radiology services in the outpatient department of a hospital or facility. You have been asked to pay a $100 copayment for the diagnostic mammogram, and a $230 copayment each for the digital breast tomosynthesis and breast ultrasound. The diagnostic mammogram falls within the x-rays in the outpatient department of a hospital or facility benefit category. The digital breast tomosynthesis and breast ultrasound fall within the diagnostic radiology services in the outpatient department of a hospital or facility benefit category. This means that you have been asked to pay the correct amounts 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 for the diagnostic mammogram, digital breast tomosynthesis, and breast ultrasound you had at an outpatient hospital facility on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the primary care physician (PCP) services rendered on July 6, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you were advised that the provider took your insurance. The Plan denied your request. The Plan says the coinsurance 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 50% of the Medicare allowed amount for each out-of-network primary care provider visit for Medicare-covered services.
Review of the file shows that you received out-of-network primary care services on July 6, 2021. You have been asked to pay 50% of the Medicare allowed amount for these services. These services fall within the out-of-network primary care provider visit for Medicare-covered services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan is not denying coverage for these services. The amount you are being asked to pay 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 the primary care physician (PCP) services rendered on July 6, 2021.