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

We decided that the Plan does not have to waive the copayment for physical therapy provided from August 18, 2020, through September 14, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were told your appointments would be $30 per session. You say that you don't feel liable for the extra charges. The Plan denied your request. The Plan says the copayments 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 $40 copayment for Medicare-covered physical therapy and speech therapy services. You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $360 ($40/visit x 9 visits = $360). Physical therapy falls 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 for physical therapy provided from August 18, 2020, through September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient appears to be improving but recent increase in oxygen requirement suggesteda need for additional non-complex short-term acute care services which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available and covered at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from March 1, 2020,
through March 27, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that the doctor recommended he stay in
the hospital. You say that you are appealing the room and board cost. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay $0 per day for days 1-20 and $178 per day for days 21-100 for each SNF stay.
The enrollee has been asked to pay a $3,026 copayment for the SNF stay.
Dates of Service SNF Days Number of Days Copayment Member Liability
February 19, 2020-
February 29, 2020
1 to 11 11 $0/day $0
March 1, 2020-
March 9, 2020
12 to 20 9 $0/day $0
March 10, 2020-
March 27, 2020
21 to 37 17 $178/day $3,026
TOTAL: $3,026
The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that the
enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for the SNF stay provided from March 1, 2020, through March 27, 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.
You asked the Plan to pre-approve IRF care. You say that medical literature demonstrates the superiority of
acute inpatient rehab in functional outcomes for stroke patients. The Plan denied your request. The Plan says
the enrollee does not require an intensity of rehab services, or close physician involvement.
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 was admitted to the acute hospital for left sided weakness and was treated for a stroke. Her
medical conditions are stable. The complexity of her nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical
record documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program.
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 pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is 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 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient's functional status requires or can tolerate an 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-approveacute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the residual tooth root removal provided on June 3, 2020.
You asked the Plan to pay for the residual tooth root removal. You say that there was not enough tooth to repair the crown, so the oral surgeon removed the tooth. You say that you are appealing the $290 charge. The Plan denied your request. The Plan says payment cannot be issued for services performed by a provider that has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the residual tooth root removal provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 19, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodontal scaling and root planing (D4342) for the lower left quadrant provided on August 10, 2020.You asked the Plan to pay forthe dental service. You say that you had sore gums. You say that it was painful for you to chew or eat solid foods. You say that panoramic images were necessary to determine the cause of your pain and a plan for treatment. You also say that periodontal scaling was deemed the necessary form of treatment.The Plan denied your request. The Plan says periodontal scaling and root planing is not listed as a covered service.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 forthe periodontal scaling and root planing (D4342) for the lower left quadrant provided on August 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided on May 3, 2018.
You asked the Plan to pay for occupational therapy. You say that the original claim submission was prior to the
timely filing deadline. You say that you are requesting immediate payment. The Plan denied your request. The
Plan says the claim was received past the allowed twelve-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for occupational therapy was not filed until August 18, 2020. This means that
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for occupational therapy provided on May 3, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of chest (71046) provided on
August 5, 2020.
You asked the Plan to waive the copayment for the x-ray of chest. You say that you do not believe you owe a
copayment. The Plan denied your request. The Plan says the copayment 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 $100
copayment for basic radiological services.
You have been asked to pay a total cost share of $80.04 for the x-ray of chest which is less than the required
$100 copayment. The service provided falls within the basic radiological 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 the x-ray of chest (71046) provided on August 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Myrbetriq 50 mg tablet.
You asked the Plan to pre-approve Myrbetriq. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited to those drugs covered under the enrollee's medical benefit only.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Myrbetriq 50 mg tablet.
Benefits for Myrbetriq may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), bitewing x-rays (D0274), and the prophylaxis (D1110) provided on August 26, 2020.
You asked the Plan to pay for the dental services. You say that you have had previous claims from this provider paid. You say that you were not notified that the provider was no longer in your network. You say that you are very upset and should not have to pay this bill. You say that you should have been notified of the change. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that services that you receive out of network are not covered. The Plan also says that periapical x-rays are not listed as covered services.
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, dental services that you receive out of network are not covered. Additionally, periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), bitewing x-rays (D0274), and the prophylaxis (D1110) provided on August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient mental health care provided from August 14, 2020, to August 26, 2020.You asked the Plan to pay forthe inpatient mental health care. You say that the inpatient mental health care was medically necessary.The Plan denied your request. The Plan says the inpatient mental health care was not medically reasonable and necessary, and care would have been appropriate at lower level.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 the inpatient mental health care. Our reviewer says that the service was not medically necessary and reasonable. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Although it didappear that the records were supervised and evaluated by a physician, there does not appear to have been an individualized treatment plan. 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 mental health care have not been met.Therefore, we decided that the Plan does not have to pay forthe inpatient mental health care provided from August 14, 2020, to August 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam received on August 31, 2020.
You asked the Plan to waive the copayment for the exam. You say that this should be free. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.
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 Medicare-covered eye exams. You have been asked to pay a $40 copayment for the exam. the exam falls within the Medicare-covered eye exams 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 eye exam received on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual wellness visit (G0439), the periodic comprehensive preventive medicine reevaluation (99397), and the electrocardiogram (93000) rendered by the out-of-network (OON) provider on October 5, 2020.You asked the Plan to pay forthese 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 forthe annual wellness visit (G0439), the periodic comprehensive preventive medicine reevaluation (99397), and the electrocardiogram (93000) rendered by the out-of-network (OON) provider on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on May 27, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 14301 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers mustreport services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.We find that CPTcode 14301 is not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer to any area. 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 pay forthe surgical services rendered on May 27, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided on
September 7, 2020, September 9, 2020, and September 23, 2020.
You asked the Plan to waive the copayment for emergency room services. You say that you shouldn't be
expected to pay because you feel that the services rendered while you were in the emergency department were
inadequate or insufficient. The Plan denied your request. The Plan says emergency room visits have a $120
copayment.
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 $120
copayment for Emergency care.
You have been asked to pay a $120 copayment for emergency room services. Emergency room visits fall
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
room services provided on September 7, 2020, September 9, 2020, and September 23, 2020.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the
appropriate Quality Improvement Organization for further review.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care on July 13, 2020,
through July 29, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You said that you never left the hospital
and therefore, should not have a second copayment. The Plan denied your request. The Plan says the service at
issue was a more intensive level of care and therefore, falls under a separate admission to the hospital.
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 $325 for
days 1-6 for inpatient hospital care.
You have been asked to pay a $325 copayment per day, for days 1-6 of each of your inpatient hospital
admissions. The services at issue fall 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 copayment for inpatient hospital care on July 13, 2020, through July 29, 2020