Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the colonoscopy provided on June 24, 2020.

You asked the Plan to waive the cost for the colonoscopy. You say that the provider is in-network and you were informed the copayment was $400. You say that you assumed the procedure was covered and you would be financially better if the claim was denied. The Plan denied your request. The Plan says the cost share applied correctly.

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 your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan also says that you must pay 50% coinsurance for surgery services at an out-of-network outpatient hospital or ambulatory surgical center." 

The item or service you asked the Plan to waive the cost for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on June 24, 2020. Therefore, $500 has been applied to meet your deductible.

Since the $500 deductible was met you have also been asked to pay $125.04, which is 50% of the allowed amount for the colonoscopy. The allowed amount is $250.06 (50% x $250.06 = $125.04). 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 for the colonoscopy provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the inpatient hospital care provided January 10, 2019, to January 14, 2019.

You asked the Plan to waive the deductible for the inpatient hospital care. You say that you would like this deductible to be waived. The Plan denied your request. The Plan says the cost share has processed correctly in this case.

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 $1000 deductible for inpatient hospital care. 

You have been asked to pay a total cost share of $309.11 for the inpatient hospital care because you had not fulfilled the deductible. This care 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 deductible for the inpatient hospital care provided January 10, 2019, to January 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 3, 2021.

You asked the Plan to waive the copayment for the office visit. You say that you have a lot of doctor bills to pay and you cannot pay this charge. 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 $30 per specialist visit.

You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and service provided on January 5, 2021 by
an out of network provider.

You asked the Plan to pay for the office visit (99214) and incision and drainage of abscess (10060). You say
that you would like the Plan to review the medical records and pay the claim. The Plan denied your request.
The Plan says prior authorization was not obtained as required.

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 office visit and service provided on January 5, 2021 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.

You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided support the medical necessity of an inpatient hospital admission. The Plan denied your request. The Plan says the approved elective total knee arthroplasty can be provided in an outpatient setting. The Plan says that the clinical scenario does not warrant an inpatient admission.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for an inpatient hospital admission have been met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled to have a knee arthroplasty. The records provided do not indicate the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights. The record does not indicate why, if necessary, the initial day cannot be spent in observation until it is clearly expected that a second midnight would be required, at which time the physician may order inpatient admission. The elements of the coverage rule are not satisfied. The requested service cannot be recommended 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 inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 11, 2021.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services (11042, 11043, 11044) and the chemical cauterization of granulation tissue (17250) rendered by the out of network (OON) provider on
March 29, 2021.

You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior 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 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 debridement services (11042, 11043, 11044) and the chemical cauterization of granulation tissue (17250) rendered by the out of network (OON) provider on March 29, 2021.
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 clinical information provided supports the need
for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have
not been met. The Plan says that the enrollee's care can be provided safely at a less intensive setting of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
has a past medical history of spinal stenosis, hypertension, COPD, and pancreatic cancer and is living at home with increasing weakness and trouble walking. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genomind testing.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that Genomind testing is covered when specific criteria are met. 

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that the test was ordered at the request of the enrollee. The submitted records are insufficient to determine that the coverage criteria are satisfied. The testing is therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Genomind testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ECG provided on March 8, 2021.

You asked the Plan to waive the copayment for the ECG. You say that you were billed for something you don't believe you had done. 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 $20 copayment for diagnostic tests in a physician's office.

You have been asked to pay $16.59, which is less than the standard $20 copayment for the ECG. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the ECG 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 ECG provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider
on February 18, 2021.

You asked the Plan to pay for the laboratory test. You say that you were not aware of the requirement of
obtaining prior authorization. You say that the referring provider deemed the service was medically necessary
and are requesting reconsideration of benefits. The Plan denied your request. The Plan says prior authorization
was required but not obtained.

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 for the laboratory test provided by an out-of-network provider on February 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for and hold the enrollee harmless for physician's services provided on February 24, 2021, and February 25, 2021.

You asked the Plan to pay for the physician's services. You say that you were not seen by this doctor. The Plan denied your request. The Plan says that the records show that you saw this physician on these dates of service.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for the physician's services by a contract facility. The file does not show that the Plan provided notice that the physician's services would not be covered prior to the services being provided. Under Medicare rules, this means the physician's services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for and hold the enrollee harmless for physician's services provided on February 24, 2021, and February 25, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve service and maintenance on your stationary oxygen concentrator.

You asked the Plan to pre-approve service and maintenance on your stationary oxygen concentrator. You say that you do not know why the provider would want to come out and service the equipment. The Plan denied your request. The Plan says you are not yet eligible for service.

The Plan must follow Medicare rules. The rules say that M&S services are to begin no sooner than 6 months following the end of the rental period and billed after the visit. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of service and maintenance on your stationary oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve service and maintenance on your stationary oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), fillings (D2392 x2), an intraoral periapical radiographic image (D0220), and a crown (D2740) provided on January 4, 2021.

You asked the Plan to pay for a limited oral evaluation, fillings, an intraoral periapical radiographic image, and a crown. You say that you were not aware that the services would not be covered, and you should not be responsible for any amount. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), fillings (D2392 x2), an intraoral periapical radiographic image (D0220), and a crown (D2740) provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 25, 2021.

You asked the Plan to pay for the periodontal maintenance. You say that you upgraded your dental coverage which was to be effective on January 1, 2021. You also say that periodontal maintenance is covered under the upgraded benefit. The Plan denied your request. The Plan says this service is not covered. The Plan also says that the internal documentation system does not reflect your benefit plan change.

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. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making (99204) provided February 25, 2021.

You asked the Plan to waive the copayment for the office visit. You say that the exam should be covered with $0 copayment as a glaucoma screening. The Plan denied your request. The Plan says the service was correctly processed as a medical eye exam and the copayment was assessed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. 

You have been asked to pay a $45 copayment for the medical eye exam. The medical records show that several medical conditions were discussed during the eye exam and the service was correctly processed as a medical eye exam. 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 or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making (99204) provided February 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance services (A0427), and ground mileage (A0425) provided on June 5, 2020.

You asked the Plan to waive the copayment for emergency ambulance services, and ground mileage. You say that you cannot afford the charges and want the Plan to pay. The Plan denied your request. The Plan says the copayment was 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 $265 copayment for ambulance services. 

You have been asked to pay a $265 copayment for emergency ambulance services, and ground mileage. The services at issue fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency ambulance services (A0427), and ground mileage (A0425) provided on June 5, 2020.