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

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from May 12, 2018 to May 19, 2018.
You asked the Plan to waive the copayment for inpatient stay. You say that you believe this should be treated
as part of the same incident as previous hospital admissions and that you should not be liable for this amount.
The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $295
copayment per day for days 1 to 5 and $0 copayment for additional days for in-network inpatient stay. At the
time this claim was processed, $2,810.48 of the $3,900 in-network maximum out-of-pocket amount had been
met. This inpatient stay lasted 7 days, resulting in a copayment obligation of $1,089.52 which meets the $3,900
in-network maximum out-of-pocket amount for 2018.
You have been asked to pay $295 copayment per day for days 1 to 5 and $0 copayment for additional days for
inpatient stay. Inpatient 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 an inpatient hospital stay provided from
May 12, 2018 to May 19, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says skilled nursing care is not required, as defined by Medicare rules.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral for otolaryngology services at the Medical Center for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no delay or access issue noted that would require treatment at a tertiary care center.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the referral. Our reviewer says that the requested referral is considered medically reasonable and necessary in this case. Our physician reviewer found based on the imaging, the enrollee has had a right cervical metastatic lesion since July 2019. Unfortunately, the enrollee was not referred for a biopsy until November 2019, which then showed metastatic squamous cell carcinoma. She did not see an ENT until January 2020. At this point, it is likely that the enrollee is suffering from cancer of unknown primary since there was no aerodigestive lesion noted on her CT scan. Cancer of unknown primary (CUP) is a difficult condition to treat and requires specialty care. In addition, this enrollee's malignancy has been present for at least 6 months, if not longer. Therefore, treatment will be more challenging and requires specialty care. It is highly likely she will require dual modality treatment, in the form of surgery followed by XRT/chemo, or XRT first followed by surgery. She will also need oral surgery evaluation for possible dental extractions prior to XRT. This coordination of care is best done at an academic facility where the enrollee can be presented and evaluated by a tumor board. Most community ENTs are not equipped to coordinate care for complex cancer patients who require dual modality treatment. The member absolutely qualifies for urgent tertiary level of specialty care. 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 referral have been met. Therefore, we decided that the Plan has to pre-approve a referral for otolaryngology services at the Medical Center for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening for "short chain fatty acid" (82542) provided to the enrollee on March 10, 2019.You asked the Plan to pay for this testing. You say that this claim should be paid.The Plan denied your request. The Plan says this testing is not covered by Medicare.The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed above, are not covered.The services provided were considered screening tests and are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for screening for "short chain fatty acid" (82542) provided to the enrollee on March 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the services can be provided on an outpatient basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there is no need for skilled therapy or skilled nursing services. The provided medical records do not indicate a need for inpatient services. Care in the nursing facility with custodial services appears to be appropriate at this 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered  on June 18,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services you received from August 2, 2019 to October 15, 2019.
You asked the Plan to pay for the services provided. You say that the copay were only to be $10. The Plan denied your request. The Plan says the copays were applied based on your plan benefits.
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 $10 copay for services in a primary care office, and a $30 copay for services in a specialist office.
The file shows that you received physician services from a specialist provider on August 2, 2019. You were originally charged a $23.70 copay for the services provided. As a courtesy, the Plan has agreed to reprocess the claim to apply only a $10 copay. We found no exception which would require the Plan to further reduce the copay.
The file shows that you received physician services from a specialist provider on September 13, 2019. You were charged a $23.70 copay for the services provided. Because the amount is less than your $30 specialist copay, you were charged the lesser amount.
The file shows that you received physician services from a specialist provider on October 15, 2019. You were charged a $20 copay for the services provided. The records show that you also received services from a primary care provider on the same date of service, and were charged a $10 copay. Because you already received a copay from the primary care services, you were only charged a $20 copay for the specialist services. We found no exception which would require the plan to further reduce the copay for the services provided.
The services fall within the physician 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 further pay for the physician services you received from August 2, 2019 to October 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on May 8, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered to the enrollee on May 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on March 21, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claimfor these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on March 21, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient office visit and injection treatment provided on November 26, 2019 by an OON provider.You asked the Plan to pay forthe outpatient office visit and injection treatment. You say that these services were needed.The Plan denied your request. The Plan says the attending provider is a non-participating provider. The Plan also says that prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from networkproviders. 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 forthe outpatient office visit and injection treatment provided on November 26, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99334) provided on May 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that the doctor was not responsible for authorization. The Plan denied your request. The Plan says these services were not authorized.
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 the domiciliary or rest home visit (99334) provided on May 31, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing forinjections, X-Ray examinations, and outpatient hospital services provided on October 7, 2019.You asked the Plan to waive the cost-sharing forinjections, X-Rays, and outpatient hospital services. You say that you believe these charges are incorrect.The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.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 injections, $110 copayment for X-Rays, and $285 copayment for outpatient hospital services. The allowed amount of the injection is $14.24, resulting in a coinsurance amount of $2.85. You have also been asked to pay $110 copayment for X-Rays provided at the hospital. For the outpatient hospital professional and surgical services you have been asked to pay the allowed amount of $117.18, which is less than the $285 copayment for outpatient hospital services. Your total cost-sharing obligation is therefore $230.03.You have been asked to pay 20% coinsurance for injections, $110 copayment for X-Rays, and less than $285 copayment for outpatient hospital services. Injections, X-Rays, and outpatient hospital services fall within the "Medicare Part B Prescription Drugs", "Outpatient Diagnostic Tests and Therapeutic Services and Supplies", and "Outpatient Hospital Services" benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost-sharing forinjections, X-Ray examinations, and outpatient hospital services provided on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 4, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered tothe enrollee on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hyperbaric oxygen therapy (HBOT) unit.
You asked the Plan to pre-approve the HBOT unit. You say that the enrollee has chronic headaches due to traumatic brain injury and needs extra oxygen to the brain in order to prolong life and quality of life. The Plan denied your request. The Plan says Medicare does not cover HBOT for this enrollees condition.
The Plan must follow Medicare rules. Medicare rules say that HBOT is covered for the treatment of the above listed conditions. The enrollee does not have a covered indication for the use of HBOT. Therefore, we decided that the Plan does not have to pre-approve a hyperbaric oxygen therapy (HBOT) unit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Porlastin-C (J0256).
You asked the Plan to pre-approve Porlastin-C. You say that the medication is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Porlastin-C. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review indicates that the documentation does not support that the Porlastin-C is medically reasonable and necessary for the enrollee. The documentation does not support that the Porlastin-C is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Porlastin-C have not been met. Therefore, we decided that the Plan does not have to pre-approve Porlastin-C (J0256).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 10, 2019.You asked the Plan to pay for lab tests. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not covered for the diagnoses listed and were performed for screening purposes.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).You asked the Plan to pay fora pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis.The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675, E0673).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF care is medically necessary.The Plan denied your request. The Plan says rules for coverage have 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 on Medicare guidelines. Our physician reviewer found the patient does not meet criteria for IRF admission. The patient was medically stable. She may benefit from further physical and occupational therapy but this can be provided on an outpatient basis.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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection of platelet rich plasma provided on September 6, 2019.You asked the Plan to pay for injection of platelet rich plasma. You say that you had this injection because you wanted to have the best chance to heal and get back to a normal way of life.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that injections of platelet rich plasma are not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection of platelet rich plasma have not been met.Therefore, we decided that the Plan does not have to pay foran injection of platelet rich plasma provided on September 6, 2019.