Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the vestibular function testing and audiologic function testing you received on June 21, 2021.  You asked the Plan to waive the deductible for the vestibular function testing and audiologic function testing . You say that this was part of your preventive annual hearing exam and there should be no copayment. The Plan denied your request. The Plan says you were assessed this deductible 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 there is a $500 deductible that applies to diagnostic hearing services.   You had not yet met your deductible at the time of the vestibular function testing and audiologic function testing. The vestibular function and audiologic function testing services you received are not part of a routine hearing exam, regardless of the reason for the services.  These are diagnostic hearing services to which the deductible applies.  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 deductible for the vestibular function testing and audiologic function testing you received on June 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the computed tomographic angiography (CTA) of the chest with low osmolar contrast material you had on July 16, 2021.
You asked the Plan to waive the cost sharing for the CTA with low osmolar contrast material. You say that you have had this test before and didn't have a copayment. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that because the allowed amount for this service ($274.22) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan says that you were charged 20% coinsurance for the low osmolar contrast material correctly as well.
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 diagnostic imaging and 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $300 copayment for the CTA and 20% coinsurance for the low osmolar contrast material. The CTA falls within the diagnostic imaging benefit category and the low osmolar contrast material is a Medicare Part B drug. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the computed tomographic angiography (CTA) of the chest with low osmolar contrast material you had on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on July 21, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the charges because the provider was rude and told you to see your primary care physician. 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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall within the urgently needed services 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 urgently needed services provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interspinous distraction device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar spinal stenosis with neurogenic claudication. The vertiflex device is experimental. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interspinous distraction device (Vertiflex).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not have a need for daily skilled nursing or therapy care.  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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, continued dialysis, and was treated for a urinary tract infection. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was at a contact guard assist level with bed mobility and transfers. He required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. He does not require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided on June 25, 2021.
You asked the Plan to waive the coinsurance for radiation therapy. You say that you were told that you would owe about $400 and feel that you were misquoted. 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 radiation therapy. You received radiation therapy on June 25, 2021. The total allowed amount is $15,684.44 and 20% of that is $3,136.88. You have been asked to pay the total coinsurance amount of $3,136.88 for radiation therapy. Radiation therapy 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 coinsurance for radiation therapy provided on June 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient cataract surgeries provided on August 19, 2021, and September 2, 2021.
You asked the Plan to reduce the copayment for the cataract surgery. You say that you think the cost sharing amount seems excessive. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290 copayment for each outpatient surgery at an ambulatory surgical center. You have been asked to pay a $290 copayment for each cataract surgery. The cataract surgeries fall 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 reduce the copayment for the outpatient cataract surgeries provided on August 19, 2021, and September 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on June 22, 2021.
You asked the Plan to waive the copayment for an X-ray. You say that you did not receive services at the provider listed on the claim. 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 $150 copayment for outpatient hospital services, including X-rays. The medical records show that you received X-rays at an outpatient hospital facility on June 22, 2021. Therefore, you are responsible to pay the allowed amount of $42.57, which is less than the $150 copayment. You have been asked to pay $42.57 for an X-ray. An X-ray falls within the outpatient hospital services 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 X-ray provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 14, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric care from December 14, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from December 14, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of December 14, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond December 14, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from December 14, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 14, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure (CPAP) device and supplies you received on June 26, 2021.
You asked the Plan to waive the coinsurance for the CPAP device and supplies. You say that you feel this should be covered because the doctor told you that you needed it to keep your breathing from stopping and to prevent stroke. The Plan denied your request. The Plan says these items were not denied. Rather, you were charged the appropriate cost sharing for these items.
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 CPAP device and supplies. The CPAP device and
supplies fall within the durable medical equipment 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 continuous positive airway pressure (CPAP) device and supplies you received on June 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from June 17, 2021, to July 22, 2021.
You asked the Plan to waive the copayments for outpatient mental health care. You say that you were told by a Plan representative that you would not owe anything for outpatient mental health visits. 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 $40 copayment for outpatient mental health care.
You received outpatient mental health care from June 17, 2021, to July 22, 2021, for a total of 4 visits.
Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40
(copayment) x 4 (visits) = $160.
You have been asked to pay the total copayment amount of $160 for outpatient mental health care. Outpatient
mental health care falls within the outpatient mental health 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 copayments for outpatient mental health care provided from June 17, 2021, to July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July, 30, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and not a full visit. 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 $30 copayment for specialist visits. You received a specialist visit on July 30, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on July, 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management service provided on March 4, 2021.
You asked the Plan to pay for hospital discharge day management service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 hospital discharge day management service provided on March 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on June 22, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were told that the hospital would take care of this cost and you weren't expecting to receive a bill. 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 copayment applies regardless of the reason for the transport and regardless of who orders the transport. 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 June 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on April 17, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were in need
of care due to a fall taken while on vacation and you believe that the Plan should fully or partially cover the
services as they were needed even though you chose not to be transported. The Plan denied your request. The
Plan says your plan covers ambulance transportation only when you are actually transported by ambulance.
Since you were not transported by this ambulance, the service is not covered under your Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on April 17, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport
(A0998) provided on April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 25, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the Plan paid the maximum allowed benefit of $150 for the eyeglasses. Since your eyewear purchase costs more than $150 allowance, you are responsible to pay the difference.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 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 paid the maximum allowed benefit of $150 for the eyeglasses. Since your eyewear purchase costs more than $150 allowance, you are responsible to pay the difference. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on August 5, 2021.
You asked the Plan to waive the copayment for podiatry services. You say that you saw a flyer that said you would not owe anything for a diabetic foot exam. 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 $40 copayment for podiatry services. The medical records show that you received podiatry services beyond routine footcare provided on August 5, 2021. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for podiatry services. Podiatry services fall within the podiatry services 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 podiatry services provided on August 5, 2021.