Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from
March 13, 2021, to March 20, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you 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 a $320
copayment for days 1-5 for inpatient hospital care.
You received inpatient hospital care from March 13, 2021, to March 20, 2021. Therefore, you are responsible
to pay a $320 copayment for days 1-5 (March 13, 2021, to March 17, 2021). The total amount you owe is: $320
(copayment) x 5 (inpatient days) = $1,600.
You have been asked to pay the total copayment amount of $1,600 for inpatient hospital care. Inpatient hospital
care 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 inpatient hospital care provided from March 13, 2021, to March 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the X-ray exam of the shoulder (73030) provided on May 20, 2021.
You asked the Plan to waive the copayment for the X-ray exam of the shoulder. You say that you believe you do not owe a cost sharing amount. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
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 Medicare-covered X-ray and ultrasounds. You have been asked to pay a $60 copayment for the X-ray exam of the shoulder. This service falls within the Medicare-covered X-ray and ultrasounds benefit category. Although your provider referred to this as a deductible, this is incorrect. The service has been correctly charged as a copayment. 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-ray exam of the shoulder (73030) provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the records show that you have chronic obstructive pulmonary disease (COPD) and asthma with previous hospital admissions for worsening of these conditions. There are no pulmonary function tests in the submitted records supporting a diagnosis of obstructive lung disease and no arterial blood gas testing showing carbon dioxide retention. You do not meet the criteria for coverage and the home ventilator is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services.
You asked the Plan to pay for the acupuncture services. You say that according to the verification of this
benefit, pain management should be covered. Please reprocess. The Plan denied your request. The Plan says the
acupuncture services was provided by a non- covered provider type.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the
Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of
the acupuncture services have not been met. Specifically, the services were rendered by a non-covered provider
type, a licensed acupuncturist, not a physician. This provider is not supervised by a physician, PA, or NP/CNS.
Therefore, we decided that the Plan does not have to pay for acupuncture services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging and does not have to waive the coinsurance for medical supplies provided on August 3, 2021.

You asked the Plan to waive the copayment for myocardial perfusion imaging and to waive the coinsurance for medical supplies. You say that you had a stress test and received a bill with two different charges that you disagree with. 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 $125 copayment for radiological diagnostic services, and 20% coinsurance for medical supplies.

You received myocardial perfusion imaging on August 3, 2021. Therefore, you are responsible to pay the $125 copayment. 

You received medical supplies on August 3, 2021. The total allowed amount is $508 and 20% of that is $101.60. 

The total amount you owe is: $226.60. 

You have been asked to pay the total amount of $226.60 myocardial perfusion imaging and medical supplies. Myocardial perfusion imaging and medical supplies 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 myocardial perfusion imaging and does not have to waive the coinsurance for medical supplies provided on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device (22869).
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria has not been met.
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 a Vertiflex Superion device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found in this case, there are multi-level spinal degenerative abnormalities that are
plausible pain generators (and which have not been entirely elucidated and/or otherwise ruled-out.) A lack of
contraindications such as significant scoliosis and osteoporosis has also not been specifically documented.
Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's
medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and
necessary for treatment of this enrollee's medical condition.
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 Vertiflex Superion device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Vertiflex Superion device (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on June 1, 2021.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the eye refraction
is not covered by Medicare.
Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state
of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered
diagnosis or treatment of illness or injury.
We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in
connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the
Plan does not have to pay for an eye refraction provided on June 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a non-emergency ambulance transport rendered on July 29, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you are on a fixed income and did not request for the ambulance ride. The Plan denied your request. The Plan says the cost-sharing was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for Ambulance Services.
You have been asked to pay a $293.88 copayment for ambulance services. The services at issue fall within the Ambulance Services benefit category. Since the allowed amount of $293.88 is less than the contractually required $325 copayment, you are responsible for the lesser amount. 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 non-emergency ambulance transport rendered on July 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided from July 21, 2020, to July 22, 2020.
You asked the Plan to pay for the outpatient hospital services. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 21, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided from July 21, 2020, to July 22, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management, more than 30 minutes, provided on April 9, 2020.
You asked the Plan to pay for the physician service. You say that the enrollee was not enrolled in hospice at the time the services were rendered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management, more than 30 minutes, provided on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 13, 2021 by an out-of-network (OON) provider.
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 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 laboratory services provided on August 13, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular genetic testing provided on July 1, 2021.

You asked the Plan to pay for the testing services. You say that there is no diagnosis limitation for the codes.
The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment
panels for suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file, and Medicare rules. Panel testing is not specific to the enrollee's lipid abnormality or
disease. Based on this information, we decided that Medicare rules for coverage of the testing services have not
been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic testing
provided on July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 25
to September 2, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee should not
have to pay a charge for a second hospital stay because the enrollee never should have been discharged in the
first place. The Plan denied your request. The Plan says the correct copayment was applied.
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 $325 copayment for each day of days 1-5 of an inpatient hospital stay.
The enrollee has been asked to pay $1,625, or a $325 copayment for each day of days 1-5 of an inpatient
hospital stay. An inpatient hospital stay falls within the "Inpatient hospital care" benefit category. 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 waive the copayment for an inpatient hospital stay from August 25 to September 2, 2020.
Your complaint about being charged for a second hospital admission that should not have been necessary is not
a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on July 14, 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 were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed adjacent to the CPT code for GeneSight testing. 

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - resin-based composite (indirect) (D2710) provided September 1, 2021.
You asked the Plan to pay for the resin-based composite crown. You say that you don't understand why this service isn't covered. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 crown - resin-based composite (indirect) (D2710) provided September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight rollator.

You asked the Plan to pre-approve an ultra-lightweight rollator. You say that other walkers are too heavy for the enrollee to remove from their car. The Plan denied your request. The Plan says this device is not covered according to Medicare rules.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Specifically, the record indicates the enrollee will be putting it in her car and using it when outside the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve an ultra-lightweight rollator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 23, 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.

The Plan must follow Medicare rules. The rules say that urinalysis is the standard of care for UTI. 

We looked at the file and Medicare rules. The file shows that the services at issue exceeded the standard of care for the diagnosis and treatment of a UTI. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99349) provided on June 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the treating provider is not a network provider with the Plan. The Plan also says that this service was not urgent or emergent, nor was it approved in advance.
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 that the Plan does not have to pay for the home visit (99349) provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve lumbar RFA services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Medicare guidelines only allow this procedure twice in one rolling 12 month period.
The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. In this case, the record confirms that the enrollee received two RFA procedures in April 2021. Therefore, the benefit has been exhausted at this time according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar radiofrequency ablation (RFA) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0273) provided on September 1, 2021.

You asked the Plan to pay for the dental services. You say that you are retired and on a limited income. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says 1 set of bitewing x-rays are covered per plan year. The Plan also says the frequency limit has been exceeded.

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 and bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on August 25, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0273) provided on September 1, 2021.