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

We decided that the Plan does not have to waive the copayment forphysical therapy services (97110) received June 2 through June 23, 2020.You asked the Plan to waive the copayment forphysical therapy services. You say that you thought your insurance was active and paying for these services.The Plan denied your request. The Plan says the correct copayment amounts were applied.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 copayment amount for Outpatient Rehabilitation Services. You have been asked to pay a $20 copayment for each of six physical therapy visits, totaling a $120 copayment amount. Physical therapy visits fall within the Outpatient Rehabilitation 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 forphysical therapy services(97110) received June 2 through June 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglasses provided on November 6, 2020.You asked the Plan to pay foreyeglasses. You say that the service should be covered.The Plan denied your request. The Plan says the maximum allowed under your benefit was exceeded.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of eyeglasses every year with a $125 allowance.We looked at the file and the Plan's rules. You haveexceeded the maximum allowed for this service and, therefore, the service is not covered. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay foreyeglasses provided on November 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided.

You asked the Plan to pay for post stabilization care. You say that the service was medically necessary.The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized ,and subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 post stabilization care. Our reviewer says that the service is not medically necessary. Our physician reviewer found, the enrollee had been deemed "hemodynamically stable "and "clinically stable" by two treating physicians. At this time he was hemodynamically stable for ambulance transfer with monitoring to a Plan facility. All inpatient care provided after ,was not needed on an emergent basis. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post dstabilization care have not been met. Specifically, prior authorization was not obtained to continue services after the patient stabilized.Therefore, we decided that the Plan does not have to pay for post stabilization care provided.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on February 4, 2020, and March 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on February 4, 2020, and March 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lightweight manual wheelchair.
You asked the Plan to pre-approvea lightweight manual wheelchair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not medically necessary.The Plan follows Medicare rules. Medicare rules say that lightweight manual wheelchairs are only covered for certain indications.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 lightweight manual wheelchair. Our reviewer says that the documentation does not support that the requested Our physician reviewer found you have knee pain and osteoarthritis and are reported to be unable to walk due to knee pain. Based on the medical records provided there is no documentation that you meet all of the LCD criteria for the requested lightweight wheelchair. There is no documentation that your mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. There is no documentation that your home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is requested. There is no documentation that you have sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is requested in the home during a typical day. There is no documentation that you have a caregiver who is available, willing, and able to provideassistance with the wheelchair. Therefore, you do not meet criteria for the requested item.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 lightweight manualwheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea lightweight manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental consultation with a prosthodontist.You asked the Plan to pre-approvea dental consultation with a prosthodontist. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says dental services are only covered when performed by a participating general dentist. The requested prosthodontist is not considered to be a general dentist.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 dental consultation with a prosthodontist is not among those covered under this benefit. The Plan contract clearly says that in order for dental services to be covered, they must be performed by a participating general dentist. A prosthodontist is not considered to be a general dentist.Therefore, we decided that the Plan does not have to pre-approvea dental consultation with a prosthodontist
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHumira for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee has had positive clinical results with this medication.The Plan denied your request. The Plan says that this is not covered under Part B.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-approveHumira for theenrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 the services are not covered.

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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam and to pay for the eye
refraction rendered on October 16, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was applied correctly and the eye refraction is not
covered.
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 exams to diagnose and treat diseases and conditions of the eye.
Review of the file shows that you had an eye exam on October 16, 2020. You have been asked to pay a $40
copayment for these services. These services fall within the exams to diagnose and treat diseases and
conditions of the eye 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.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.
The file shows that you also received an eye refraction on October 16, 2020. These services are considered
routine vision care and are not covered by Medicare.
Therefore, we decided that the Plan does not have to waive the copayment for the eye exam and to pay for the
eye refraction rendered on October 16, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's needs could be safely met at a lower level of care, such as a skilled nursing facility.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for bilateral total knee replacement. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on August 22, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because the service you received was horrible. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on August 22, 2020.
We note your complaint that you are unhappy with the service you received. Your complaint is a grievance that must be answered by the health 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 pay forthe medical services provided to the enrollee on February 12, 2020, by an out-of-network provider.You asked the Plan to pay forthe medical services. You say that the claim should be paid.The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider and the services were not urgent or emergent, nor were they approved in advance.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 medical services provided to the enrollee on February 12, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on July 22, 2020.
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 the services are not covered.
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. The services at issue are extraspinal manipulation billed with code 98943. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the cervical spine (72040), hot or cold packs therapy (97010), and the electric stimulation therapy (97014) provided from November 5, 2020, through November 11, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or by Medicare.
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 (99202), x-ray exam of the cervical spine (72040), hot or cold packs therapy (97010), and the electric stimulation therapy (97014) provided from November 5, 2020, through November 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the hope of the rehab is to regain a level of mobility to go to a lower level of care such an assisted living home.The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF services.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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reduce the cost-sharing charges for the placement of ureteral stent provided on August 7, 2020
You asked the Plan to reduce the cost-sharing charges for the placement of ureteral stent. You say that you feel that this is a continuation of a previous surgery and should have the same copayment charge instead of the coinsurance charges. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The Plan says you must pay $563.39 for the placement of ureteral stent. Based on the Plan contract, however, you cannot be asked to pay more than a $250 copayment for the placement of ureteral stent. Therefore, we decided that the Plan has to reduce the cost-sharing charges for the placement of ureteral stent provided on August 7, 2020 from $563.39 to $250.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from January 31, 2020, through February 2, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says that the services were 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 correctin denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that it was reasonable to believe the enrollee's inpatient stay 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 been met. Specifically, it was reasonable to believe the enrollee's stay would span two midnights making the inpatient care reasonable and necessary.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from January 31, 2020, through February 2, 2020.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided.

You asked the Plan to pay for July the ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services provided.