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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 5, 2019 through June 6, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment 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 patient's necessary hospital care (including earlier ED and/or observation 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 pay for the acute inpatient hospital care provided from June 5, 2019 through June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 18, 2019You asked the Plan to waive the copayment forthe specialist office visit. You say that you did not receive the injection during this appointment and needed to make another appointment. 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 $40 copayment for each specialist visit for Medicare-covered services. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a re-evaluation of right shoulder pain.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 specialist office visit provided on October 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen provided from June 19, 2019 through August 19, 2019.You asked the Plan to waive the coinsurance for the oxygen. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file show that you received oxygen from June 19, 2019 through August 19, 2019. You are asked to pay 20% coinsurance for each date of 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 coinsurance for oxygen provided from June 19, 2019 through August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and presumptive drug tests provided from October 17, 2017 to May 8, 2019 by out of network provide.  You asked the Plan to pay for the out-of-network services. You say that in-network providers cannot provide the help you need. The Plan denied your request. The Plan says there is no valid referral for the 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 file shows that you received out-of-network services on October 17, 2017, November 14, 2017, November 13 and 26, 2018, and May 8, 2019. The requested provider is not a network provider with the Plan. The Plan has network providers available who can provide 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 out-of-network services. Therefore, we decided that the Plan does not have to pay for the office visits and presumptive drug tests provided from October 17, 2017 to May 8, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ambulance service and emergency room visit on May 1, 2019, a hospital visit on June 19, 2019, and physical therapy visits from June 18, 2019 to June 28, 2019.You asked the Plan to waive the copayments foran ambulance service, an emergency room visit, a hospital visit, and physical therapy visits. You say that you should not owe these copayments.The Plan denied your request. The Plan says these services processed correctly.The rules say a plan must disclose to its enrollees in clear, accurateterms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each Medicare-covered ambulance trip, a $75 copayment for each Medicare-covered emergencyroom visit, a $275 copayment for Medicare-covered outpatient hospital and observation services, and a $25 copayment for outpatient rehabilitation services, including physical therapy.
You have been asked to pay $275 for an outpatient hospital visit, and $100 for four physical therapy visits ($25 x 4 visits= $100). You have also been asked to pay $200 dollars for an ambulance service and $75 dollars for an emergency room visit. The record does not show that you were admitted as inpatient following these 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 foran ambulance service and emergency room visit on May 1, 2019, a hospital visit on June 19, 2019, and physical therapy visits from June 18, 2019 to June 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 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, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexilant DR 60 MG Capsules.
You asked the Plan to pre-approve Dexilant. You say that the Dexilant is medically necessary. The Plan denied your request. The Plan says coverage for this drug is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dexilant DR 60 MG Capsules.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis provided on July 26, 2019.You asked the Plan to pay forthe knee orthosis (L1833). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says criteria for the orthoses have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. There is no clinical documentation of knee instability or joint laxity. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy (97124) and electric stimulation (97032) provided on August 2, 2018 through August 24, 2018.
You asked the Plan to pay for the massage therapy and electric stimulation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these are not covered services when billed by a chiropractor.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for massage therapy (97124) and electric stimulation (97032) provided on August 2, 2018 through August 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services you provided to the enrollee on April 8, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is a non-participating provider billing for unauthorized 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 rendering 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 medical services you provided to the enrollee on April 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 8, 2019 by out of network provider.You asked the Plan to pay forthe scheduled ambulance transport. You say that the transport was medicallynecessary.The Plan denied your request. The Plan says the services were rendered without 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 forthe ambulance services provided on June 8, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on July 17, 2019 by out of network provider.
You asked the Plan to pay for the surgical services. The Plan denied your request. The Plan says the services were not urgent or emergent. The Plan also says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services could have been provided 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 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 surgical services provided on July 17, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 6, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to an hour to set up the Heart Lung Machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service would be included in the part-A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayments for the laboratory services provided on July 18, 2019 and the occupational therapy evaluation. We decided that the Plan does not have to waive the copayments for the laboratory services provided on July 17, 2019 and the laryngoscopy.
You asked the Plan to waive the copayments for the laryngoscopy, laboratory services and occupational therapy evaluation. You say that you were informed the stay would be less because you were in observation. The Plan says that the copayments applied correctly.
We decided that the Plan has to reduce the copayments for the laboratory services provided on July 18, 2019 and the occupational therapy evaluation.
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 Plan contract says that you must pay a $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility) and a $0 copayment after the deductible is met for each therapy visit.
The Plan says that you must pay $14.88 for laboratory services on July 18, 2019 and $89.97 for the occupational therapy evaluation. Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for the laboratory services and a $0 copayment for the occupational therapy evaluation. Therefore, we decided that the Plan has to reduce the copayment for the laboratory services from $14.88 to $10 and waive the copayment for the occupational therapy evaluation.
We also decided that the Plan does not have to waive the copayments for the laboratory services provided on July 17, 2019 and the laryngoscopy.
Your contract with the Plan clearly says that you must pay a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility and a $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). Therefore, we decided that the Plan does not have to waive the copayments for the laboratory services provided on July 17, 2019 and the laryngoscopy.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab tests provided on August 28, 2019.You asked the Plan to waive the copayment forlab tests. You say that you have never been charged in the past 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 $15 copayment for lab tests. You have been asked to pay the allowed amount of $7.60, which is less than the $15 copayment for lab tests. Lab tests fall 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 forlab tests provided on August 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 15, 2019 to September 17, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for this copayment because the first hospital you went to was not able to treat you. 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 $325 copayment per day, for days 1-5 for inpatient hospital care. You have been asked to pay a $325 copayment for each day of the inpatient hospital stay. ($325 x 2 = $650). The inpatient hospital stay falls within "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 stay provided from September 15, 2019 to September 17, 2019.
Your complaint about the poor treatment from the staff at the hospital 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue additional payment for the resin-based composite, two surfaces, posterior filling (D2392) provided on August 12, 2019.
You asked the Plan to issue additional payment for these services. You say that according to the benefits booklet, The plan should be responsible to pay 75% of the allowable charges. The Plan denied your request. The Plan says the claim was processed correctly to apply the in-network level of benefit for restorations.
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 50% coinsurance for restorations provided by an in-network dental provider. You have been asked to pay $74.50 for these dental services. These services fall within the in-network supplemental dental benefit category. The allowable charge for the dental services was $149. Your coinsurance responsibility is $74.50, 50% of the allowable charge. 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 issue additional payment for the resin-based composite, two surfaces, posterior filling (D2392) provided on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 26, 2019 by the out of network provider.
You asked the Plan to pay for laboratory tests. You say that the treating physician regarded this test as medically necessary, and you believe the standard for urgently needed services is applicable. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 medical services provided on June 26, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal manipulation (98943) provided on August 6, 2019.
You asked the Plan to pay for the extraspinal manipulation. You say that you would like reconsideration as these services have been covered in the past. The Plan denied your request. The Plan says the extraspinal manipulation (98943) is not a covered chiropractic service.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extraspinal manipulation (98943) provided on August 6, 2019.