Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided on January 23, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that you were never informed of the potential costs for these services. 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 $50 copayment per specialty care visit. You have been asked to pay a $50 copayment for the specialist office visits. The specialist office visits fall 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 copayments for the specialist office visits provided on January 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on January 20, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you needed your medication adjusted and had to keep asking the staff to put the reason for your visit down. 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 an ER visit. An ER visit 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 an ER visit provided on January 20, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71046) provided on January 29, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service
was billed with the correct diagnosis code. The Plan denied your request. The Plan says that the chest x-ray
cannot be reimbursed separately.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not forward any evidence of the procedure of which CPT code
71046 is integral to. There is no evidence of payment for any procedures in which payment for the x-ray would
be included. The Plan has also not forwarded sufficient information to substantiate a denial based on the
diagnosis code billed. Therefore, we decided that the Plan has to pay for a chest x-ray (71046) provided on
January 29, 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 26, 2019 through December 31, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 26, 2019 through December 31, 2019.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter placement provided on November 20, 2019.
You asked the Plan to waive the copayment for the catheter placement. You say that you already met your maximum out-of-pocket. You say that the claim should be recalculated with no copayment due. 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 $250 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $250 copayment for the catheter placement. The catheter placement falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that a previous claim was reprocessed, which reduced the amount you paid toward your maximum out-of-pocket cost. 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 catheter placement provided on November 20, 2019.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary.
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 records indicate this enrollee suffered a left corona radiata ischemic infarct. Hospital course has included management of neurological status, speech therapy for aspiration issues, and physical therapy for mobility and balance impairment. Mild cognitive impairment persists. The co-morbid conditions include diabetes. Now, neurological status and hemodynamics are stable. The enrollee is minimal/moderate assist for transfers and activities of daily living's. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate/minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from January 28, 2020 through February 4, 2020.You asked the Plan to pay forinpatient mental health 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 psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 28, 2020 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from January 28, 2020 through February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from January 3, 2020 to February 28, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs from January 3, 2020 to February 28, 2020 for a total of 3 services. The allowed amount per each date of service is $5,639.15 and 20% of that is $1,127.83. Therefore, the total amount you owe is: $1,127.83 (coinsurance) x 3 (Medicare Part B drug services) = $3,383.49. You have been asked to pay the total coinsurance amount of $3,383.49 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided from January 3, 2020 to February 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darbepoetin alfa (J0881).You asked the Plan to pre-approve the Darbepoetin. You say that the enrollee had gotten Injectafer on June 22, 2020, and gotten the B12 and folate drawn.The Plan denied your request. The Plan says Darbepoetin alfa (J0881) is not medically necessary. The Plan also says that a repeat of enrollee's iron panel and hemoglobin level since she just received intravenous iron, Injectafer, to treat her anemia is recommended.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.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 Darbepoetin. Our reviewer says that the Darbepoetin does not meet coverage criteria.Our physician reviewer found the enrollee does not meet the listed coverage criteria because updated labs are recommended after the iron infusion to establish necessity of the Darbepoetin alfa. Our reviewer also found that a repeat iron level and hematocrit is recommended before the requested Darbepoetin alfa (J0881) can be considered medically reasonable and 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 the Darbepoetin have not been met.Therefore, we decided that the Plan does not have to pre-approve Darbepoetin alfa (J0881)
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay forthe definitive drug panel provided on November 18, 2019.You asked the Planto pay forthe definitive drug panel. You say that this testing was medically necessary and ordered by the treating physician.The Plandenied your request. The Plansaysthatthe documentation provided does not include a complete order form.The Plan must follow Medicare rules. Medicare rules say that laboratory testing may be covered when ordered by the treating provider.In this case, although the second page of the order form is missing, the form does include the electronic signature of the ordering provider. The laboratory also included a copy of the form signed by this provider in which this provider's custom profile is documented. There is sufficient evidence that the provider intended to order the drug testing that was provided. Denial of payment based on no valid order is not supported in this case.Therefore, we decided that the Planhas to pay forthe definitive drug panel provided on November 18, 2019.If the Plandoes 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/orsend 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of impacted tooth (D7230), first 15 minutes of IV moderate (conscious) sedation/analgesia (D9239), and each subsequent 15 minute increment of IV moderate (conscious) sedation/analgesia (D9243 x3) provided on January 28, 2020.
You asked the Plan to pay for the removal of impacted tooth and sedation/analgesia services. You say that you believed these services would be covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.
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 removal of impacted tooth (D7230), first 15 minutes of IV moderate (conscious) sedation/analgesia (D9239), and each subsequent 15 minute increment of IV moderate (conscious) sedation/analgesia (D9243 x3) provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.You asked the Plan to pre-approve an office visit. You say that you have had no success with any of your previous specialists.The Plan denied your request. The Plan says there are in-network providers available.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on February 14, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you were not aware that you would be charged in addition to the doctor's specialist visit. 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 $150 copayment per visit for all other outpatient diagnostic and therapeutic services and supplies, such as MRAs, MRIs, CT scans, PET scans, and hyperbaric oxygen therapy. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $150 copayment for the CT scan.
You have been asked to pay a $149.34 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the incumbent exercise bike purchased December 19, 2019
from an out-of-network provider.
You asked the Plan to pay for the exercise bike. You say that you paid $674.99 out of pocket. Upon purchasing
the bike you were told you could be reimbursed for it through the insurance. The Plan denied your request. The
Plan says this item is not covered by Medicare. This provider is not a certified Medicare provider.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for the incumbent exercise bike purchased December 19, 2019 from
an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the leuprolide acetate suspension provided on March 4, 2020.
You asked the Plan to waive the coinsurance for the leuprolide acetate suspension. You say that you have cancer and this is part of your treatment. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a Cost 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 Medicare Part B covered chemotherapy drugs and other Part B covered drugs. You have been asked to pay $184.06, which is 20% of the allowed amount for the leuprolide acetate suspension. The allowed amount is $920.28 (20% x $920.28 = $184.06). The leuprolide acetate suspension falls within the "Medicare Part B prescription drugs" 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 coinsurance for the leuprolide acetate suspension provided on March 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the office visit (99214) rendered by the out of network (OON) provider on January 8, 2018.You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service was 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 has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99214) rendered by the out of network (OON) provider on January 8, 2018.