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

We decided that the Plan does not have to pre-approve acute IRF admission and service.You asked the Plan to pre-approve IRF care. You say that transfer to a lower level of care would place the enrollee at a significant risk for complications, morbidity, and re-hospitalization.The Plan denied your request. The Plan says the enrollee has a minimum decline of his prior level of functioning.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 physician reviewer found that the enrollee is medically stable with no evidence of need for supervision by an acute rehab physician, or acute rehab nursing care. He may benefit from further physical and occupational therapy, but does not require an intensive therapy program with IRF admission with the current level of function with min assist and low endurance. Therefore, an IRF admission is not 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on July 13, 2019 to August 5, 2019.You asked the Plan to waive the copayment for urgent care services. You say that you were told that your copayment would be $30. You say that now you are getting charged an additional $20. You say that you were misinformed and should not have to pay the difference.The Plan denied your request. The Plan says the correct copayment has been 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 a $50 copayment for urgently needed services. You have been asked to pay a $50 copayment for urgent care services. The total amount you are being asked to pay is $100 ($50 x 2 visits = $100). The correct copayment has been applied to the service that was provided. Urgent care services fall within the urgently needed 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 urgent care services provided on July 13, 2019 to August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 31, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is no valid referral for this service.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 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 nurse practitioner services provided on August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services provided to the enrollee on July 28, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services would be included in the Part A payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The assembly and operation of pump with oxygenator or heat exchanger services was provided to the enrollee. We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the special pump services provided to the enrollee on July 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 10, 2019 to June 30, 2019.You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services.The Plan denied your request. The Plan says the Medicare criteria for SNF level of coverage were not met.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 10, 2019 to June 30, 2019
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the breathing capacity test. We decided that the Plan does not have to waive the copayments for the electrocardiogram and chest x-ray. You asked the Plan to waive the copayments for the breathing capacity test, electrocardiogram and chest x-ray.You submitted your bill for review. You say that you want this bill resolved.The Plan says that the copayments applied correctly.
We decided that the Plan has to reduce the copayment for the breathing capacity test. The rules say a health 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 $20 copayment for outpatient diagnostic tests atthe PCP, physician specialist and free standing clinic.The Plan says you must pay $24.78 for the breathing capacity test. Based on the Plan contract, however, you cannot be asked to pay more than $20. Therefore, we decided that the Plan has to reduce the copayment for the breathing capacity test from $24.78 to $20. We also decided that the Plan does not have to waive the copayments for the electrocardiogram and chest x-ray.Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests in the PCP, physician specialist and free standing clinic and a $30 copayment for x-rays. You have been asked to pay $14.36 for the electrocardiogram and $24.72 for the chest x-ray which are less than the standard copayments.Therefore, we decided that the Plan does not have to waive the copayments for the electrocardiogram and chest x-ray.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 BLS emergency ambulance service (A0429) and ground mileage (A0425) provided on December 7, 2018.
You asked the Plan to pay for the ambulance services. You say that this claim needs to be reprocessed to correctly reflect patient responsibility. The Plan denied your request. The Plan says the information provided does not support medical necessity for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 the ambulance services. Our reviewer says that the documentation did not support that the ambulance transport was medically reasonable and necessary. Our physician reviewer found the documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The enrollee was alert and oriented with stable vital signs. There was no documented need for BLS or ALS monitoring or intervention. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for BLS emergency ambulance service (A0429) and ground mileage (A0425) provided on December 7, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for echocardiographs provided on July 15, 2019 and August 13, 2019.
You asked the Plan to waive the copayments for echocardiographs. 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 a $0 copayment for outpatient x-ray services provided by a primary care physician or free-standing radiology clinic and a $100 copayment for services provided by a specialist at an outpatient hospital. You received an echocardiograph on July 15, 2019. Therefore, you are responsible to pay the allowed amount of $16.63, which is less than the $100 copayment. You received an echocardiograph provided on August 13, 2019. Therefore, you are responsible to pay the $100 copayment. The total amount you owe is: $116.63. You have been asked to pay the total allowed amount of $116.63 for echocardiographs. Echocardiographs 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 copayments for echocardiographs provided on July 15, 2019 and August 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient hospital stay providedf rom May 14, 2019 to May 16, 2019. You asked the Plan to waive the coinsurance for an outpatient hospital stay. 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 outpatient services including observation and outpatient surgical services.You had an outpatient hospital stay from May 14, 2019 to May 16, 2019. The allowed amount is $11,071.38 and 20% of that is $2,214.28.  You have been asked to pay the total coinsurance amount of $2,214.28 for an outpatient hospital stay. An outpatient hospital stay falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an outpatient hospital stay provided from May 14, 2019 to May 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission beginning August 7, 2019.You asked the Plan to pre-approve the SNF admission. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says any therapy needs can be provided at a lower level of care such as home health care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approv eskilled nursing facility (SNF) admission beginning August 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and laryngoscopy provided on May 6, 2019.
You asked the Plan to waive the deductible for the office visit and laryngoscopy. You say that the deductible was met in March. You say that the claim should be reprocessed. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan says that the deductible amount for Medicare Part B services is $185. Until you have paid the deductible amount, you must pay the full cost for Medicare Part B services. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that the $185 deductible applies to specialist services. This cost sharing is a contractual obligation that had not been met at the time the office visit and laryngoscopy were received on May 6, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the office visit and laryngoscopy provided on May 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from September 6, 2019 to September 13, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from September 6, 2019 to September 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 11, 2019 to August 18, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not supported in the medical record. Specifically, code S9328 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9328 provided from August 11, 2019 to August 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ExoDx Prostate IntelliSCore (EPI) provided to the enrollee on June 6, 2019.
You asked the Plan to pay for the services provided. You say that the definitive analysis was critical in determining the appropriate treatment assessment for the enrollee. The Plan denied your request. The Plan says the testing is not covered by Medicare, and is not considered medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The EPI is deemed investigational due to lack of independent validation, false negatives, and short follow-up. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ExoDx Prostate IntelliSCore (EPI) provided to the enrollee on June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services provided on August 9, 2019 and August 23, 2019.You asked the Plan to waive the copayments for the specialist services. You say that you would have never had the services done if had known about the copayments.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 $25 copayment for services obtained from an in-network specialist. You have been asked to pay a $25 copayment for each of the specialist services. ($25 + $25 = $50). The specialist services 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 services provided on August 9, 2019 and August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, and blood draw provided on August 7, 2019 by the out of network provider.You asked the Plan to pay for the practitioner services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 office visit, and blood draw provided on August 7, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services provided on June 12, 2019 by out of network provider.
You asked the Plan to pay for the office visit and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit and related services provided on June 12, 2019 by out of network provider.