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

 We decided that the Plan has to waive the copayment for the blood draw associated with the hemoglobin A1C test you had on July 8, 2021. We decided that the Plan does not have to waive the copayment for the urine microalbumin level lab test with blood draw you had on March 3, 2021.   You asked the Plan to waive the copayments for the lab services. You say that you are entitled to a hemoglobin A1C lab test at $0 copayment.  You said that the blood draw is necessary to complete the hemoglobin A1C test, so there should be no copayment.  The Plan says that you were charged these copayments correctly.  The Plan says that the blood draw is separate from the hemoglobin A1C test, so the copayment can apply to that portion of the service.  We decided that the Plan has to waive the copayment for the hemoglobin A1C test with blood draw you had on July 8, 2021.   Your Evidence of Coverage states that enrollees pay a $0 copayment for diabetic lab tests for hemoglobin A1C.  There is no language in the contract that would indicate that separate cost sharing would apply for the blood draw necessary to complete the hemoglobin A1C.  A reasonable layperson would have no reason to believe that cost sharing would apply to the blood draw services associated with this test that is supposed to be covered at 100%.  As the drafter of the contract, the Plan is responsible for ensuring that they properly disclose all cost sharing obligations.  We find that they have not done so on this specific instance. Therefore, we decided that the Plan has to waive the copayments for the hemoglobin A1C test with blood draw you had on July 8, 2021.   We also decided that the Plan does not have to waive the copayment for the urine microalbumin level lab test with blood draw you had on March 3, 2021.  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 the lab services. This test is not a hemoglobin A1C test that is free from copayments.  This specific test is a lab service to which a copayment appropriately applies.  Although you may have also received a hemoglobin A1C test on this same day, no cost sharing was charged for that portion of the claim. Therefore, we decided that the Plan does not have to waive the copayments for the urine microalbumin level lab test with blood draw you had on March 3, 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 out of network physician services provided on July 16, 2021.  You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 out of network physician services provided on July 16, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.  You asked the Plan to pre-approve continuation of SNF care. You say that SNF care continues to remain medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for SNF care is no longer met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the member did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care with minimal improvement. His function had plateaued by November 20, 2021, and he did not require any further inpatient skilled rehab services. The member's function was at or near his new baseline level of function and he could be discharged to a lower level of care for further services.  As of November 20, 2021, the member required custodial services. The denial for further inpatient skilled care is upheld.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to reduce the coinsurance for the portable oxygen system (code E0431) and the oxygen concentrator (code E13090) you rented from January 18, 2021, to March 15, 2021.  You asked the Plan to reduce the coinsurance for the oxygen equipment. You say that you believe the supplier is overcharging you for these items. The Plan denied your request. The Plan says you were charged this coinsurance 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 durable medical equipment.     You have been asked to pay 20% coinsurance for the oxygen equipment. The allowed amounts for the portable oxygen system (code E0431) and the oxygen concentrator (code E13090) are $19.83 and 103.26, respectively. This means that your monthly 20% coinsurance amount is $24.62 ($19.83 + $103.26 = $123.09; $123.09 x 20% = $24.62). 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 coinsurance for the portable oxygen system (code E0431) and the oxygen concentrator (code E13090) you rented from January 18, 2021, to March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the measles, mumps, and rubella virus vaccine (90707) and vaccine administration (90471) provided on June 22, 2021.  You asked the Plan to pay for the vaccine and vaccine administration services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says these services are not covered by Medicare.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine and vaccine administration services. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the vaccine and vaccine administration services. Therefore, we decided that the Plan does not have to pay for the measles, mumps, and rubella virus vaccine (90707) and vaccine administration (90471) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the primary care visit you had on June 22, 2021.  You asked the Plan to waive the copayment for the primary care visit. You say that your Medicare and Veteran's Affairs (VA) insurance should be primary, and you should not have any copayments. The Plan denied your request. The Plan says you are not enrolled in Original Medicare- you are enrolled with the Plan, which is a Medicare replacement plan.  The Plan is your primary insurer for services that you receive outside of a VA facility. The Plan says that 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 $15 copayment for primary care visits.   You have been asked to pay a $15 copayment for the primary care visit. 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 primary care visit you had on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the magnetic resonance imaging of the brain (MRI) you had on May 27, 2021.  You asked the Plan to waive the coinsurance for the MRI. You say that your Medicare and Veteran's Affairs (VA) insurance should be primary, and you should not have any copayments. The Plan denied your request. The Plan says you are not enrolled in Original Medicare- you are enrolled with the Plan, which is a Medicare replacement plan.  The Plan is your primary insurer for services that you receive outside of a VA facility. The Plan says that 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 20% coinsurance for MRIs.  You have been asked to pay 20% coinsurance for the MRI. 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 MRI you had on May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the osteopathy services provided on August 2, 2021, by a provider who has opted out of Medicare.
You asked the Plan to pay for the osteopathy services. You say that you believe out of network providers are covered by your Plan. The Plan denied your request. The Plan says the provider who has rendered the services in question has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the osteopathy services provided on August 2, 2021, by a provider who has opted out of Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for hearing aids provided on July 12, 2021.  You asked the Plan to waive the copayment for hearing aids. The Plan denied your request. The Plan says the benefit applied correctly. In accordance with the member 2021 Evidence of Coverage member hand booklet which states; there is a $999 copayment that applies for premium digital hearing aids.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the Plan applied the hearing aid benefit correctly. Therefore, we decided that the Plan does not have to waive the copayment for hearing aids provided on  July 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided outside of the United States from July 2, 2020, to December 23, 2020.  You asked the Plan to pay for the medical care provided in another country. You say that these services were urgent and medically necessary. You did not have the option to return home for care due to the pandemic. The Plan denied your request. The Plan says only emergency care received outside of the United States is eligible for coverage. No documentation was provided to support that the services at issue were urgent, emergent, or post-stabilization care. Therefore, these services are denied.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  Medicare rules also say that in order to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the medical care provided in another country have not been met. Specifically, there is no documentation provided to support that the services at issue were medically necessary and met the criteria for urgent/emergent services provided out-of-country. Therefore, we decided that the Plan does not have to pay for the medical services provided outside of the United States from July 2, 2020, to December 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a retroperitoneal ultrasound (76770) rendered on July 26, 2021.  You asked the Plan to waive the copayment for a retroperitoneal ultrasound. You say that the cost of the lab test (kidney ultrasound) should be covered in full. You also say that the Plan should pay you back. The Plan denied your request. The Plan says you were 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 $95 copayment for basic radiological services in an outpatient hospital.   You have been asked to pay a $95 copayment for a retroperitoneal ultrasound. Retroperitoneal ultrasounds fall 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 a retroperitoneal ultrasound (76770) rendered on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for medical services provided on July 6, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the medical services. You say that the office told you that this doctor was in-network with any plan and your regular physician was not available to see you. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.  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 cannot be held responsible for incorrect information provided to you by this out-of-network provider. 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 medical services provided on July 6, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Mohs surgery you had at an ambulatory surgery center on January 28, 2020.
You asked the Plan to waive the copayment for the Mohs surgery. You say that you were told you would not have a copayment as long as the surgery was not outpatient or in a hospital. You said that this took place in a doctor's office, so you didn't know there would be a copayment for it. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the facility where you received these services is an ambulatory surgery center. The Plan confirmed that this surgery center is inside of the doctor's office. There are two floors at this facility: the first floor is the ambulatory surgery center, and the second floor is for clinic visits. You had this procedure in the first-floor surgery center.
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 $240
copayment for surgery in an ambulatory surgery center. You have been asked to pay a $240 copayment for the Mohs surgery. The Mohs surgery falls within the surgery in an ambulatory surgery center 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 Mohs surgery you had at an ambulatory surgery center on January 28, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the outpatient surgery services provided on May 17, 2020.
You asked the Plan to pay for the outpatient surgery services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that while payment cannot be made to a physician who has opted out of Medicare, this rule does not apply to emergency services. A Medicare plan must pay for emergency or urgently needed services given by a physician or practitioner who has not signed a private contract with the enrollee. We looked at the file and Medicare rules. Review of the file shows that the Plan has verified that the medical services were provided to the enrollee during an emergency visit at a Plan participating facility. This means the services were performed in an emergent situation and therefore, do not fall within the non-payment category. Based on this information, we decided that Medicare rules for coverage of the debridement services have been met. Therefore, we decided that the Plan has to pay for the outpatient surgery services provided on May 17, 2020.
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 waive the copayment for the urgent care visit you had on June 10, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that you believe the urgent care copayment is waived if you are admitted. 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 $45 copayment for urgent care services.   You have been asked to pay a $45 copayment for the urgent care visit. Your contract says that the emergency room copayment is waived if you are admitted.  This waiver does not apply to urgent care services at an urgent care facility, only to services in the emergency room.  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 urgent care visit you had on June 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the injection procedure you had at an outpatient hospital clinic and the injectable medication (Avastin) you received on January 5, 2021.  You asked the Plan to waive the cost sharing for the injection procedure and the Avastin medication. You say that this was one of three injections.  For the first two injections, you just paid a $40 copayment.  You stated that in January, you received the exact same service, but you are being billed much more.  You stated that you never used the facility and your copayment should only be $40. The Plan denied your request. The Plan says you were charged these cost sharing amounts correctly. The Plan also says that for the procedure itself, the allowed amount for this service ($307) is less than your copayment obligation, so you are responsible for the full allowed amount for this service.  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 $350 copayment for outpatient hospital services and 20% coinsurance for Medicare Part B drugs you receive in an outpatient hospital facility.   You have been asked to pay a $350 copayment for the injection procedure and 20% coinsurance for the Avastin medication. According to the case file documents, these services were rendered in an outpatient hospital facility setting.  Your Evidence of Coverage states that you pay separate coinsurance for Medicare Part B drugs you receive in an outpatient hospital setting. The Avastin injection you received is a Medicare Part B drug. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing applies regardless of what you may have paid in previous years. 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 injection procedure you had at an outpatient hospital clinic and the injectable medication (Avastin) you received on January 5, 2021.