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

We decided that the Plan does not have to waive the deductible for inpatient hospital services provided from May 13, 2021, to May 14, 2021.
You asked the Plan to waive the deductible for inpatient hospital services. You say that you had a medical event earlier this year where you went to the emergency room (ER) and then were admitted to the hospital. You state that you already have had a lot of out of pocket expenses. 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 pay $300 per calendar year after the deductible for inpatient hospital covered services. You have been asked to pay $300 deductible for inpatient hospital. Inpatient hospital services fall under 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 deductible for inpatient hospital services provided from May 13, 2021, to May 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient hospital services rendered
on May 17, 2021.

You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges.
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. Your
contract with the Plan says that there is $100 yearly deductible which applies to all in-network and out-ofnetwork
medical services with a coinsurance and 20% of the total cost for Medicare-covered observation
services.

The item or service you asked the Plan to waive the cost sharing for falls within the Medicare-covered
observation services benefit category. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is $100 yearly deductible which applies to all in-network and out-of-network medical
services with a coinsurance. This cost sharing is a contractual obligation that had not been met at the time these
services were received on May 17, 2021. The Plan applied a total of $100 towards your deductible for these
services. At that time, your yearly deductible had been met.

Given that the deductible charge did not cover the entire cost of the services, you have also been asked to pay
20% of the total remaining cost for these services, for a total of $13.14. The total amount you have been asked
to pay for these services is $113.14. This cost sharing is a contractual obligation that 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 outpatient hospital services
rendered on May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided December 18, 2020, to January 18, 2021.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were physically able to do all the things that were denied. 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 $275 copayment per day for days 1-5 of inpatient hospital care.

You have been asked to pay a total of $1,375 ($275 x 5 days = $1,375) copayment for the inpatient hospital stay. This inpatient hospital stay 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 the inpatient hospital admission and services provided December 18, 2020, to January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive pulmonary panel (81302, 81330, 81345,
81404, 81405, 81406, 81407, 81408, 81479) provided on September 22, 2020.

You asked the Plan to pay for a comprehensive pulmonary panel. You say that this was medically necessary.
The Plan denied your request. The Plan says there is not a sufficient physician order for this testing.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules say for Medicare 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. The physician order in the file does not indicate that the testing at
issue was medically necessary and medical records to support medical necessity. Based on this information, we
decided that Medicare rules for coverage of a comprehensive pulmonary panel have not been met. Therefore,
we decided that the Plan does not have to pay for a comprehensive pulmonary panel (81302, 81330, 81345,
81404, 81405, 81406, 81407, 81408, 81479) provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on March 31, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of any treatment for any of the required conditions.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence-based indication for the requested procedure, as required by the LCD. This is not being used as a last resort, after all other treatment modalities have failed. There has not been a trial of stimulation. Therefore, the requested stimulator is not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services you received from April 1, 2021, to April 30, 2021.
You asked the Plan to waive the coinsurance for the dialysis services. You say that you haven't had any responsibility for the claims from this provider so far this year. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that the reason why you have not yet been assessed coinsurance for January-March of 2021 is because the provider submitted the bills with errors in them, so the claims for those dates have not been paid at all yet.
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 dialysis services. You have been asked to pay 20% coinsurance for the dialysis services. 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 dialysis services you received from April 1, 2021, to April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0483) provided on September 2, 2020.

You asked the Plan to pay for a drug test. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of a drug test have not been met. Therefore, we decided that the Plan does not have to pay for a drug test (G0483) provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiology visit the enrollee had while he was in observation care at the hospital on January 12, 2021.
You asked the Plan to waive the copayment for the cardiology visit. You say that this copayment should be waived because the enrollee did not have an office visit. You said that he was in the hospital for heart catheterization at this time. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for specialist visits. The enrollee has been asked to pay a $25 copayment for the cardiology visit. The Evidence of Coverage
explicitly states that the specialist visit copayment applies if received as part of hospital observation services. The records show that the enrollee was in an observation stay at the hospital on this date. 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 the cardiology visit the enrollee had while he was in observation care at the hospital on January 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on April 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient service. You say that the service was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before the service was rendered to the enrollee. The Plan also says that the service was not urgent or emergent in nature.
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 rest home visit provided on April 16, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on May
17, 2021.

You asked the Plan to waive the coinsurance for the Prolia injection. You say that you cannot afford this
coinsurance. 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 Medicare Part B drugs.

You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Prolia
injection you received on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 11, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the closed fracture reduction procedure you had at an outpatient hospital facility on January 26, 2021.

You asked the Plan to waive the copayment for the close fracture reduction procedure. You say that you broke your wrist and went to the emergency room. You say that you had a closed reduction which took 5 minutes and you never moved from the emergency room. You said that you should not have to pay a surgical copayment because you never went to the operating room. 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 $325 copayment for outpatient surgery in an outpatient hospital facility.

You have been asked to pay a $325 copayment for the close fracture reduction procedure. The procedure you had is considered an outpatient surgery. There is no requirement in your contract that this procedure occur in an operating room in order for the copayment to apply. That is why the close fracture reduction procedure falls within the outpatient surgery in an outpatient hospital facility 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 closed fracture reduction procedure you had at an outpatient hospital facility on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81161, 81238, 81407, 81411, 81413, 81414) provided on April 5, 2021.

You asked the Plan to pay for a hereditary cardiovascular screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients.

 We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81161, 81238, 81407, 81411, 81413, 81414) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete upper and lower denture provided on April 27, 2021.

You asked the Plan to pay for the complete upper and lower denture. You say that you were told your dental coverage would go up to $3,000 or $4,000. The Plan denied your request. The Plan says the services are not covered 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 complete upper and lower denture provided on April 27, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) represented by code 95957 provided on February 18, 2021.
You asked the Plan to pay for code 95957. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 95957.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95957 is Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis).
We find that CPT code 95957 is not supported in the medical record. Specifically, there is no documentation of digital analysis of EEG to support code 95957. Based on this information, we decided that Medicare rules for coverage of code 95957 have not been met. Therefore, we decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) represented by code 95957 provided on February 18, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper denture and lower partial denture provided on May 24, 2021.
You asked the Plan to pay more for the complete upper denture and lower partial denture. You say that you only asked for the top denture, but the practice made and charged you for both. You say that you should only have to pay for the top denture. The Plan denied your request. The Plan says $1,000 was paid toward the cost of the comprehensive dental services.
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 also have a maximum benefit of $1,000 per year for comprehensive dental services. The Plan paid $1,000 toward the dentures provided on May 24, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the complete upper denture and lower partial denture provided on May 24, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation
(A0427-HH, A0425-HH).

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that the services
should be covered. 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 ambulance services.

You have been asked to pay a $250 copayment for emergency ambulance transportation. The services at issue
fall 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
emergency ambulance transportation (A0427-HH, A0425-HH).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Soliris for the enrollee.
You asked the Plan to pre-approve Soliris. You say that this drug is medically necessary for the enrollee. The Plan denied your request. The Plan says that the patient does not meet criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Soliris. Our reviewer says that Soliris is not medically reasonable and necessary for the enrollee. The Food and Drug Administration states that Soliris is indicated in adults for the treatment of generalized myasthenia gravis in patients who are anti-acetylcholine receptor antibody positive. In addition, the agency has granted an orphan drug designation for myasthenia gravis. In this case the records submitted are nearly two years old and are insufficient to establish that the enrollee has myasthenia gravis. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Soliris. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Soliris have not been met. Therefore, we decided that the Plan does not have to pre-approve Soliris for the enrollee.