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

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary for the enrollee as she has become weaker and has been falling at home.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonableand necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the member is noted to be medically stable. The records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a skilled nursing facility. In this case, the member is mostly minimal assist for functional transfers and activities of daily living (ADL).Aless intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period of time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99203), and debridement of subcutaneous tissue (11042) provided on September 5, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit, and debridement of subcutaneous tissue. You say that the patient was seen on an emergency basis and referred by his primary care physician. You were unaware an authorization was required.The Plan denied your request. The Plan saysa non-participating provider as is the referring provider listed. Our plan did not authorize any services for a non-participating provider. The services are not considered urgent/emergent in nature. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services. Prior authorization was not obtained as required under the plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollee's EOC.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit (99203), and debridement of subcutaneous tissue (11042) provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe additional three osseous surgeries and two dental adjunctive proceduresprovidedon May 28, 2019.You asked the Plan to pay forthe additional three osseous surgeries and two dental adjunctive procedures. You say that you feel that the enrollee should be reimbursed for these services as medical because the services were medically necessary due to medication that was administered to the enrollee.The Plan denied your request. The Plan says Medicare does not cover dental procedures except in certain circumstances.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.One osseous surgery was covered as a scaling and root planing procedure, and no further osseous surgeries can be covered. Although this condition may have been caused as a sideeffect of a medication, the service itself was treatment for the teeth and structures directly supporting the teeth which means these services meet the definition of a dental service, and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay forthe additional three osseous surgeries and two dental adjunctive procedures provided on May 28, 2019. Your complaint about being frustrated with the Planis 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on September 28, 2019
You asked the Plan to waive the copayment for an MRI. You say that the facility you were inpatient at did not have the right equipment so you had to be transferred and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient diagnostic tests. You have been asked to pay the allowed amount of $220.45, which is less than the $300 copayment for an MRI. An MRI 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 copayment for an MRI provided on September 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the application of vein wound compression systems provided from August 2, 2019 to September 5, 2019.
You asked the Plan to waive the copayments for the application of vein wound compression systems. You say that you should only owe $40 copayments and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the application of vein wound compression systems from August 2, 2019 to September 5, 2019 for a total of 4 visits. The application of vein wound compression systems are considered surgical procedures. Therefore, you are responsible to pay a $125 copayment per each surgical procedure. The total amount you owe is: $500.00.
You have been asked to pay the total copayment amount of $500.00 for the application of vein wound compression systems. The application of vein wound compression systems fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 the application of vein wound compression systems provided from August 2, 2019 to September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on October 10, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that you are typically charged a $55 copayment for an x-ray and office visit. You say you should not have to pay an additional $41.47 for the x-ray.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 $55 copayment for each Medicare-covered standard x-ray and ultrasound. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $55 copayment for the x-ray.You have been asked to pay a $41.57 copayment for the x-ray. The x-ray falls within "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe x-ray provided by on October 10, 2019. Your complaint about the two-hour wait time and rescheduling your appointment 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based onMedicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not appear to be able to tolerate therapy or require this therapy on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), the x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) provided by Out Of Network Provider on October 4, 2019.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the office visit (99203), the x-ray exam of the cervical spine (72040), and the x-ray exam of the lumbar spine (72100) provided on October 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient substance abuse treatment.You asked the Plan to pre-approvecontinued inpatient substance abuse treatment. You say that this is medically necessary.The Plan denied your request. The Plan says a partial hospitalization program would be more appropriate.The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary when it is medically necessary for a patient to receive detoxification and/or rehabilitation for drug substance abuse as a hospital inpatient, coverage for care in that setting is available. Coverage is also available for treatment services that are provided in the outpatient department of a hospital to patients who, for example, have been discharged from an inpatient stay for the treatment of drug substance abuse or who require treatment but do not require the availability and intensity of services found only in the inpatient hospital setting.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 continued inpatient substance abuse treatment. Our reviewer says that continued inpatient care is not medically necessary at this time. Our physician reviewer found based on the records provided, it is not expected this enrollee would improve in a reasonable period of time beyond the previously approved dates of service as he was not showing any 
dangerousness to self or others, no auditory or visual hallucinations and no aggression or threatening behavior. This patient was compliant with treatment, participating in groups. It did not appear medically necessary and reasonable to have psychiatric/detoxification care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, delusions or hallucinations or abnormal behaviors and did not exhibit any substance related withdrawal symptoms.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient substance abuse treatment have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient substance abuse treatment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 12, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were informed this doctor does the same thing as your doctor. You say that your copayment should be refunded. The Plan denied your request. The Plan says the copayment 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 $35 copayment per in-network specialist visit. You have 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 records show that an office visit was performed. 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 office visit provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe echocardiography provided on November 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that you were advised that the provider accepted your plan. You also say that is why you went to them.The Plan denied your request. The Plan says authorization was not obtained before you received the services. The Plan says that the provider, nor the facility are in network.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 forthe echocardiography  provided on November 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on July 1, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you rendered services to the patient knowing that
you are a participating provider and was under the impression that you would receive compensation for the
services. You were unaware that you were out-of-network with the patient's specific plan. You are interested to
enroll in this plan as well and will request an application. The patient required medical care. The Plan denied
your request. The Plan says the physician is a non-network provider who does not work with the
member's health plan, and the member self-directed for care. The member's primary care provider did not refer
for services. The health plan requires utilization of network providers when possible and available and requires
authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or
emergency situation, has been documented.
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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on July 1, 2019 by
an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that the referring provider was approved for the services rendered on August 27, 2019. You say that the referral # confirms this. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the referral # on file has a start date of August 28, 2019 for atrial fibrillation.
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 rendering facility is not a network provider either. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 27, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injections provided on April 23, 2019, July 16, 2019 and November 13, 2019.
You asked the Plan to waive the copayment for the lumbar injections. You say that these were always covered by your insurance. You say that the change in cost is outrageous. The Plan denied your request. The Plan says the copayments 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 $200 copayment per visit for in-network outpatient surgery. You have been asked to pay a $200 copayment for each lumbar injection. The total amount you owe is $600 ($200/injection x 3 injections = $600). The lumbar injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The lumbar injections are considered a surgical procedure. 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 lumbar injections provided on April 23, 2019, July 16, 2019 and November 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary visit provided on August 29, 2019 by an out of network (OON) provider.You asked the Plan to pay fora domiciliary visit. You say that you had no choice what doctor you saw because the doctor came to your assisted living facility.The Plan denied your request. The Plan says the referring facility is out-of-network. The plan says that no prior authorization was obtained for these services.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora domiciliary visit provided on August 29, 2019 by an out of network (OON) provider.