Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received at an outpatient hospital facility from June 14, 2021, to July 23, 2021.  You asked the Plan to waive the copayments for the PT services. You say that you have paid your $40 copayment for each visit, so you feel as though you are being charged twice. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment per visit for physical therapy services.   You have been asked to pay a $40 copayment per visit for the PT 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 copayments for physical therapy (PT) services you received at an outpatient hospital facility from June 14, 2021, to July 23, 2021.   The Explanations of Benefits submitted with this case to us only show you were charged a single $40 copayment per visit. If you are claiming that you already paid this amount to the provider and you wish to dispute their receipt of these payments, that would not be 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 waive the copayments for the ophthalmology visits you had on July 23, 2021, and July 29, 2021.  You asked the Plan to waive the copayments for the ophthalmology visits. You say that the provider used equipment that scratched your eye.  You do not feel as though you should be responsible for these copayments because you wouldn't have had to have these appointments if you hadn't had this scratch. The Plan denied your request. The Plan says you were charged these copayments correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment per visit for visits with a specialist.   You have been asked to pay a $45 copayment per visit for the ophthalmology visits. These copayments apply regardless of the reason for the visits. 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 ophthalmology visits you had on July 23, 2021, and July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) computed tomography (CT) scan from the skull to mid-thigh.  You asked the Plan to pre-approve a PET CT scan from the skull to mid-thigh. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   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 from the skull to mid-thigh. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of Sjogrens disease and no conventional imaging such as ultrasound of the abdomen and pelvis has been done. A 15-pound weight loss is not a valid indication for PET/CT absent a documented case of malignancy.  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 from the skull to mid-thigh have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) computed tomography (CT) scan from the skull to mid-thigh.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an advanced foot feature.  You asked the Plan to pre-approve an advanced foot feature. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or above.  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 an advanced foot feature. Our reviewer says that the item is not medically necessary. Our physician reviewer found records from the enrollee's medical provider do not document a need for a K3 advanced foot feature or that the enrollee is or has the potential to be a K3 ambulator for which the requested K3 advanced foot feature would be 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 an advanced foot feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot feature.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 additional acupuncture visits.  You asked the Plan to pre-approve 10 additional acupuncture visits. You say that the services are necessary. The Plan denied your request. The Plan says the benefit has been exhausted.  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, you have completed 22 acupuncture sessions from May 21, 2021 through November 17, 2021. Therefore, we decided that the Plan does not have to pre-approve 10 additional acupuncture visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that Fosamax hurt your stomach and Actonel gave you an ulcer. You say that your doctor wanted Prolia as there are less side effects. The Plan denied your request. The Plan says in order for us to cover this drug, you must have tried and failed treatment with one intravenous bisphosphonate therapy.   Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our reviewer says that the case file does not contain documentation of trial and failure of intravenous bisphosphonate therapy. Our physician reviewer found the documentation does not support that intravenous bisphosphonate therapy would likely be less effective or have adverse effects  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a shower chair.  You asked the Plan to pre-approve a shower chair. You say that you have dizzy spells and fear of falling in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network podiatrist.  You asked the Plan to pre-approve these services. You say that you need to see a foot specialist and the only in-network provider is deceased. The Plan denied your request. The Plan says the services are available from network providers.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network podiatrist.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home or in an assisted living facility with home health care or in a long-term care facility on a part time basis as needed appear appropriate in this case.  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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you had a fall in the shower and a severe blow to your head. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that  The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an ambulatory surgery center on June 22, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you thought that routine colonoscopies were covered in full. You said that you were not told that if they found something that you would have to pay. 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 $350 copayment for outpatient surgery in an ambulatory surgical center. 

You have been asked to pay a $350 copayment for the diagnostic colonoscopy. According to your contract, only screening colonoscopies are covered with no cost sharing. We looked at the medical records from this procedure. You did not have a screening colonoscopy. This procedure was performed because you had symptoms of abdominal pain and diarrhea. Because this colonoscopy was done to investigate these conditions, it is considered a diagnostic colonoscopy for which the outpatient surgery copayment 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 copayment for the diagnostic colonoscopy you had at an ambulatory surgery center on June 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the binocular microscopy service you had on June 21, 2021.

You asked the Plan to waive the copayment for the binocular microscopy. You say that no machine was used on your during this visit. You said that the provider used a hand instrument. You said that the doctor did not perform this service. The Plan denied your request. The Plan says you were charged this copayment correctl.y

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 $20 for non-radiological diagnostic services. 

You have been asked to pay a $20 for the binocular microscopy. The binocular microscopy falls within the non-radiological diagnostic services benefit category. This copayment applies regardless of who performs the service. 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 binocular microscopy service you had on June 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lumbar spine you had on August 4, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you do not believe you should be charged two separate copayments for two doctors reading the same MRI. 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 $295 copayment for high tech imaging services. 

You have been asked to pay a $295 copayment for the MRI. We confirmed that you were not charged two separate copayments for the MRI of the lumbar spine. The records show that on this date of service, you had an MRI of the lumbar spine and an MRI of the lower extremity. The MRI of the lower extremity was billed by a different provider than the MRI of the lumbar spine. These are two separate and distinct tests that each carry their own copayment. the MRI falls within the high tech imaging 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 magnetic resonance imaging (MRI) of the lumbar spine you had on August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the eye care visit you had on March 24, 2021.  You asked the Plan to waive the copayment for the eye care visit. You say that this was a follow-up visit, so there should be no copayment. 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 $40 copayment for visits with a specialist.   You have been asked to pay a $40 copayment for the eye care visit. Medicare rules state that when you have a surgery, certain postoperative visits are included in the cost for the surgery itself. However, services from physician other than the operating surgeon are not included in this global surgical package and are separately payable. That is the case here. The postoperative visit you had on March 24, 2021, was with a different physician from the one who performed your surgery. That means that a copayment can apply. 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 eye care visit you had on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from June 26, 2021, to July 1, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not think your father should have to pay this copayment.  You said that he was transferred to a hospital that could not provide the wound care he needed.  You said that he should have been transferred to an appropriate facility at the beginning. 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 $279 copayment per day for days 1-7 for inpatient hospital care.   Records show that the enrollee was in this inpatient facility for 5 days.  He was charged a $279 copayment per day, for a total of $1395. This copayment applies regardless of the reason for the admission. 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 inpatient hospital services provided from June 26, 2021, to July 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on April 27, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that the hospital had you transferred to a different facility.  You said it was the hospital's decision to transfer you and you should not be charged for this transfer. 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 $150 copayment per trip for ambulance services.   You have been asked to pay a $150 copayment per trip for the ambulance services. This copayment applies regardless of the reason for 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 April 27, 2021.