Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

 We decided that the Plan has to waive the cost-sharing charges for a telehealth facility fee. We decided that the Plan does not have to waive the cost-sharing charges for Medicare Part B drugs.   You asked the Plan to waive the cost-sharing charges for Medicare Part B drugs and a telehealth facility fee. You say that you disagree with the charges and would like the Plan to pay them. The Plan says that the claims were processed correctly and you are being charged the correct amount.  We decided that the Plan has to waive the cost-sharing charges for a telehealth facility fee.   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 does not say in clear and accurate terms how much you should expect to pay for a telehealth facility fee.   We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $12 copayment for a telehealth facility fee. The Plan contract does not clearly say how much enrollees must pay for a telehealth facility fee. 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 cost-sharing charges for a telehealth facility fee provided on September 8, 2021.   We also decided that the Plan does not have to waive the cost-sharing charges for Medicare Part B drugs.  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 Medicare Part B drugs.   You received Medicare Part B drugs on August 5, 2021. The total allowed amount is $1,458.68 and 20% of that is $291.74. Therefore, we decided that the Plan does not have to waive the cost-sharing charges for Medicare Part B drugs provided on August 5, 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: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the emergency room visit, magnetic resonance imaging (MRI), x-ray, and laboratory work provided by an in-network provider from June 29, 2021, to August 23, 2021.  You asked the Plan to waive the copayments for the emergency room visit, the MRI, the x-ray and the laboratory work. You say that you should not be responsible for the copayments. The Plan denied your request. The Plan says you have been asked to pay 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 $90 copayment for each emergency care visit, a $150 copayment each advanced imaging services (e.g., MRI, CT and PET scans, nuclear medicine, and stress tests), a $10 copayment each basic imaging service (e.g., general x-rays or ultrasound), and a $10 copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility).   You have been asked to pay a total of $255.12 for the emergency room visit, the MRI, the x-ray and the laboratory work. The emergency room visit falls within the "Emergency care services" benefit category. The MRI, the x-ray and the laboratory work fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.  Date of Service Service Allowed Amount Copayment Member Liability June 29, 2021 Emergency room visit $107.79 $90 $90 August 2, 2021 X-ray $80.02 $10 $10 August 18, 2021 Laboratory work $5.12 $10 $5.12 August 23, 2021 MRI $22763 $150 $150 Total    $255.12  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the emergency room visit, magnetic resonance imaging (MRI), x-ray, and laboratory work provided by an in-network provider from June 29, 2021, to August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a personal emergency response system.  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 covered.  The Plan must follow Medicare rules. The rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered.  The item at appeal is a personal emergency response system. While this item may be of benefit to you, it is not covered by Medicare or the Plan.        Therefore, we decided that the Plan does not have to pre-approve a personal emergency response system.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided October 20, 2021.  You asked the Plan to waive the copayment for the non-emergency ambulance service. You say that you did not request an ambulance. The Plan denied your request. The Plan says the copayment 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 $250 copayment for each one-way Medicare-covered ground ambulance trip.     You have been asked to pay a $250 copayment for the non-emergency ambulance service. The non-emergency ambulance service falls within the Ambulance 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 the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placement of an endosteal implant (D6010 x 11).  You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied your request. The Plan says implants and related services are excluded from coverage.  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 implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placement of an endosteal implant (D6010 x 11).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Continuous Glucose Monitor.  You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that you would like reconsideration because the requested CGM is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the requested CGM.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Continuous Glucose Monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for specialist visits provided on September 1, 2021, and September 17, 2021.  You asked the Plan to waive the coinsurance for specialist visits. You say that this was the only provider that could perform the surgery and you disagree with the out-of-network 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 50% coinsurance for out-of-network physician/practitioner services, including doctor's office visits.    You received specialist services from an out-of-network provider on September 1, 2021. The total allowed amount is $131.66 and 50% of that is $65.39.   You received specialist services from an out-of-network provider on September 17, 2021. The total allowed amount is $147.66 and 50% of that is $73.34.  The total amount you owe is: $138.73.   You have been asked to pay the total coinsurance amount of $138.73 for specialist visits. Specialist visits fall 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 coinsurance for specialist visits provided on September 1, 2021, and September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction (92015) provided on July 23, 2021.  You asked the Plan to pay for the eye refraction. You say that this service was provided in an appointment following your cataract surgery, and you were told this was necessary due to changes in your vision. The Plan denied your request. The Plan says eye refractions are not covered by Original Medicare. The Plan offers supplemental coverage which includes one routine (non-medical) eye exam including an eye refraction each year. Eye refractions provided outside of the annual supplemental routine eye exam are not covered. The eye refraction in this case was not provided as part of the annual routine eye exam.  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 an eye refraction only when it is provided as part of an annual supplemental routine eye exam.  We looked at the file and the Plan's rules. The eye refraction in this case was not provided as part of a routine eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be improving and only require short-term additional acute care services that can safely be administered at the current facility until a more appropriate lower level of care is arranged. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed.    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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the two resin-based composites (D2335 x2) provided on August 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay more for the resin-based composites. You say that your benefits cover 50% for this service provided OON, which should be $234. The Plan denied your request. The Plan says these services were performed by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. You are also responsible for a 50% coinsurance of the allowed amounts.  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, you are responsible for a 50% coinsurance for the resin-based composites, plus the difference between the billed amount and allowed amount because the service was received OON. Therefore, we decided that the Plan does not have to pay more for the two resin-based composites (D2335 x2) provided on August 9, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for ambulance transport and emergency room visit provided by in-network providers on September 20, 2021.  You asked the Plan to waive the copayments for the ambulance transport and the emergency room visit. You say that you should not be responsible for the copayments because you were forced to go the emergency room. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment for each way for ambulance services and a $90 copayment for each emergency care service.  You have been asked to pay a $200 copayment for the ambulance transport and a $90 copayment for the emergency room visit. The ambulance transport falls within the "Ambulance services" benefit category. 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. Therefore, we decided that the Plan does not have to waive the copayments for ambulance transport and emergency room visit provided by in-network providers on September 20, 2021.   Your complaint about the office staff 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the office visit provided by an out-of-network provider on August 10, 2021.  You asked the Plan to reduce the copayment for the office visit. You say that you are being billed a $35 copayment for a PCP visit and it should be a $10 copayment. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for out-of-network primary care physician (PCP) office visits/other health care professionals.   The enrollee has been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network. 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 the office visit provided by an out-of-network provider on August 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heavy duty extra-wide hospital bed.  You asked the Plan to pre-approve these services. You say that the enrollee keeps falling off his current bed. The Plan denied your request. The Plan says the criteria for coverage are not met.  The Plan must follow Medicare rules. The rules say that a heavy duty extra wide hospital bed (E0301, E0303) is covered the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.  We looked at the file and Medicare rules. The file shows that the enrollee weights 255 pounds. 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 heavy duty extra-wide hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an emergency response system (S5161).  You asked the Plan to pay for an emergency response system. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for coverage for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Code S5161 has a status indicator of "I" on the Physician Fee Schedule. This means that code S5161 is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of an emergency response system have not been met. Therefore, we decided that the Plan does not have to pay for an emergency response system (S5161).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the emergency room visits (99284) provided on October 26, 2021 and November 1, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.  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 each Medicare-covered emergency care service.   You have been asked to pay $200 ($100 copayment x 2) for the emergency care visits provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the emergency room visits (99284) provided on October 26, 2021 and November 1, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan (78814).  You asked the Plan to pre-approve a PET-CT scan. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested service have not been met.  The Plan follows Medicare rules. Medicare rules say that PET A imaging is promising in two scenarios: (1) to exclude AD in narrowly defined and clinically difficult differential diagnoses, such as AD versus FTD; and (2) to enrich clinical trials seeking better treatments or prevention strategies for AD.  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 PET-CT scan. Our reviewer says that the requested service is medically reasonable and necessary in this case. Our physician reviewer found that Amyloid Beta PET-CT is covered only if there is a great possibility of the patient suffering from either AD or FTD and/or the enrollee is participating in a clinical trial. According to the medical records, the differential diagnosis of FTD vs. AD is present in the enrollee. Thus, the enrollee fulfills criteria for PET-CT imaging.  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 PET-CT scan have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan (78814).   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.