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

We decided that the Plan does not have to waive the copayment fora CT scan provided by "the hospital" on August 15, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with 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 $350 copayment for outpatient diagnostic radiology services for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $350 copayment for a CT scan. A 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 fora CT scan provided by "the hospital" on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ankle x-ray provided on July 12, 2019.You asked the Plan to pay forthe radiology service. You say that you were under the impression that your Medicare Advantage plan was secondary to Medicare.The Plan denied your request. The Plan says the services you received out of the Plan's service area were not urgent or emergent in nature. The Plan also says that the service was not authorized.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiology service have not been met.Therefore, we decided that the Plan does not have to pay forthe ankle x-ray provided on July 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ultrasound provided on September 6, 2019.You asked the Plan to waive the coinsurance forthe ultrasound. You say that this is preventive maintenance. You say that you should not have a copayment.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services.You have been asked to pay $13.38, which is 20% of the allowed amount for the ultrasound. The allowed amount is $66.89 (20% x $66.89 = $13.38). The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered diagnostic radiology. 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 forthe ultrasound provided on September 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrocardiogram (EKG), laboratory services, and the hospital outpatient clinic visit provided on August 6, 2019 by the out of network provider.You asked the Plan to pay forthe outpatient hospital 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 requested provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. The Plan hasnetwork 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 thatthe Plan does not have to pay forthe electrocardiogram (EKG), laboratory services, and the hospital outpatient clinic visit provided on August 6, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora lumbar injection providedon August 12, 2019.You asked the Plan to waive the copayment fora lumbar injection. You say that you received services at a doctor's office not a hospital.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 $250 copayment for surgery services provided in an outpatient hospital facility.The record shows that you received a lumbar injection at an outpatient hospital facility on August 12, 2019. Therefore, you are responsible to pay the $250 copayment.  You have been asked to pay a $250 copayment for a lumbar injection. A lumbar injection 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 copayment fora lumbar injection provided on August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forphysician services provided by "the doctor" on September 3, 2019.You asked the Plan to waive the coinsurance forphysician services. You say that you should only owe a $45 copayment.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 50% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You received out-of-network services on September 3, 2019. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowed amount is$183.17 and 50% of that is $91.58.You have been asked to pay the total coinsurance amount of $91.58 for physician services. Physician services fall within the physician/practitioner services, including doctor's office visits benefit category. This meansthat 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 forphysician services provided by"the doctor" on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on August 13, 2019.You asked the Plan to waive the copayment for wound debridement. You say that you disagree with 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 $290 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $199.82, which is less than the $290 copayment for wound debridement. Wound debridement 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 copayment for wound debridement provided on August 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency department services (99284) provided on July 6, 2019.You asked the Plan to pay for the emergency department services. You say that the member was seen by different providers two times in the same day. The Plan denied your request. The Plan says CPT code 99284 is bundled with 99285 which was previously processed.The Plan must follow Medicare rules. Medicare rules say that If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.We looked at the file and Medicare rules.Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. More than one evaluation and management service has been billed by a provider of the same specialty on the same date of service.Therefore, we decided that the Plan does not have to pay for emergency department services (99284) provided on July 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. Yousay that the enrollee would benefit from SNF care in order to safely return home.The Plan denied your request. The Plan says the needs are mainly custodial with no daily skilled services needed.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 indenying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 12/20/2019 after a fall with head trauma. He was found to haveacute kidney injury due to dehydration. The enrollee is now mostly supervised for all care. He has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. His vital signs are stable, he is tolerating an oral diet, and has no significant bowel or bladder deficits. Pain is well controlled. As a practical matter, services are not medically necessary to be provided in the SNF 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-approveadmission to a skilled nursing facility (SNF)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that you are requesting reconsideration for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 medical services provided on July 1, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided June 5, 2019 after 10:26am to June 6, 2019.You asked the Plan to pay forthe acute inpatient hospital care provided after 10:26am on June 5, 2019 to June 6, 2019. You say that the acute inpatient hospital care admission was medically necessary.The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 10:26 amon June 5, 2019 and subsequent care was post-stabilization of care, not approved in compliance with the health plan's authorization procedures. The Plan has paid for all emergent care up to the point of stability.The Plan must follow Medicare rules, which say that emergencycare is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care provided after 10:26am on June 5, 2019 to June 6, 2019. Our reviewer says that the services provided do not meet criteria for coverage. Our physician reviewer found that the enrollee arrived at the department on June 4, 2019 by ambulance from his dialysis center due to worsening epigastric pain for the last few days. By 10:26 amon June 5, 2019, the enrollee was stable for transferto a Plan facility. The review has determined that the enrollee was hemodynamically stable for ambulance transport with monitoring to a Plan facility as of 10:26 a.m. on June 5, 2019. Post-stabilization of care services from June 5, 2019 after 10:26am throughJune 6, 2019 at the non-Plan facility,were not medically necessary and reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acute inpatient hospital care provided after 10:26am on June 5, 2019 to June 6, 2019 have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided June 5, 2019after 10:26 amto June 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide services.You asked the Plan to pre-approvethese services. You say that the submittedrecords show that you are not homebound. You were being seen on an outpatient basis for treatment of a buttock mass without reported requirement of an assistive device. You had a normal neurological exam. There are no identified skilled nursing or skilledtherapy needs. The home health aide services are not reasonable or medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 enrolleeWe 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-approvehome health aide services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee from July 26, 2019 to July 28, 2019.You asked the Plan to pay forthe SNF services. The Plan denied your request. The Plan says that the enrollee was not receiving any skilled services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee from July 26, 2019 to July 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services (13101 and 11403) provided on August 27, 2019 by out of network provider, "the doctor".You asked the Plan to pay forsurgical services. You say that you were told this provider is in-network.The Plan denied your request. The Plan says these services were received from an out-of-network provider without 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 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 forthe surgical services (13101 and 11403) provided on August 27, 2019 by out of network provider, "the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on February 14, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you disagree with 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 a Medicare Part B drug injection on February 14, 2019. The allowed amount is $1,116.60 and 20% of that is $223.32. You have been asked to pay the total coinsurance amount of $223.32 for a Medicare Part B drug injection. A Medicare Part B drug injection 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 fora Medicare Part B drug injection provided on February 14, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay forthe outpatient physical therapy and occupational therapy (PT/OT) provided on August 6, 2019. You asked the Plan to pay for the outpatient PT and OT services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services are not covered.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. Specifically, if an out-of-network provider is appealing for payment of a service and the plan is saying this may be covered but the Evidence of Coverage says authorization is required, this is not a legitimate denial rationale. Furthermore, the plan also denies payment stating that review of the medical records for the services appealed does not show that Medicare criteria have been met. However, the case file the plan sent to us has no medical records for review. The plan has failed to submit this case file in accordance to the rules set forth in the Part C Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance Manual.Therefore, we decided that the Plan has to pay for the outpatient physical therapy and occupational therapy (PT/OT) provided on August 6, 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: 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. You say that Colonial Oaks requested for the nurse practitioner to see the enrollee and the services were provided in good faith. The Plan denied your request. The Plan says there is no valid referral for this serviceMedicare 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 servicesat 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.