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

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on May 27, 2019 by an out-of-network provider.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says they paid an emergency room (ER) facility claim; however, this provider billed this service as inpatient and not as ER.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.Claim number 1911120M0131 denied due to the provider being out-of-network and there was not an approved physician assistant (PA)on file. In order for it to be plan directed care, we must have a paid facility claim billed with the same location code or referral from a contracted provider. There is a paid facility claim billed by the provider, however, that claim was billed for ER services with location code of 23. The professional claim for physician was billed as inpatient with a location code of 21.Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on May 27, 2019 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).You asked the Plan to pre-approve the complete maxillary denture and mandibular partial denture. You say that your current dentures will not fit anymore because you were scheduled to have 3 molars removed. You also say that you will not be able to chew.The Plan denied your request. The Plan says the services you requested are only covered one time in a 60 -month period. The Plan also says that you have already received one of each of these services within that time period.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, complete maxillary denture (either D5110 or D5130) and mandibular partial denture (either D5212, D5214, D5226, or D5281) are each limited to one per 60 months. The record shows that you received these services on March 29, 2017and your complete maxillary denture benefit and mandibular partial denture benefit are now exhausted.Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an Annual Wellness Visit provided by physician on December 12, 2019.You asked the Plan to pay for Annual Wellness Visit. You say that your doctor told you that you needed this visit.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Annual Wellness Visit is only covered once every 12 months and a previous Annual Wellness Visit was provided to youon March 18, 2019.The Plan must follow Medicare rules. Medicare rules say that an Annual Wellness Visit is not covered by Medicare if a previous Annual Wellness Visit has been provided within the past 12 months. We looked at the file and Medicare rules. A previous Annual Wellness Visit was provided to you on March 18, 2019, therefore 12 months had not come to pass before this Annual Wellness Visit was performed. Based on this information, we decided that Medicare rules for coverage of Annual Wellness Visit have not been met.Therefore, we decided that the Plan does not have to pay foran Annual Wellness Visit provided by physician on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto Respimat for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Stiolto Respimat for the enrollee.
Benefits for this drug 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation services (G0378) provided from October 19, 2019 to October 20, 2019 by the provider.
You asked the Plan to waive the copayment for the hospital observation services. You say that you should not be responsible for the copayment since you were informed you were going to be admitted. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment for observation care. You have been asked to pay $200 for the hospital observation services. Hospital observation services fall within the observation 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 hospital observation services (G0378) provided from October 19, 2019 to October 20, 2019 by the provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on October 5, 2019.You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan says that the claim processed 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 $240 copay for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $240 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip via ground ambulance 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 copay for the ambulance transport provided on October 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on October 15, 2019.
You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan
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 a psychiatric diagnostic evaluation provided on October 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSNFcare provided to the enrollee from October 4, 2019 through October 22, 2019.You asked the Plan to pay forSNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could have been provided at a lower level of care (ex. home, AL, LTC).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plandoes not have to pay forSNF care provided to the enrollee from October 4, 2019 through October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee will require continued medical management of comorbidities, and daily physical and occupational therapies to address current deficits.The Plan denied your request. The Plan says that the enrollee's medical conditions are stable, and does not require frequent physician management.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 status-post hospitalization as described above with lower extremity weakness of unclear etiology with the differential diagnosis including critical illness myopathy. The enrollee has multiple complex medical conditions. Further work-up of his profound weakness is indicated. There would be an expected need to modify his treatment in orderto maximize his capacity to benefit from rehabilitation such as through lower extremity bracing. He has already failed SNF level care, and physician supervision at an acute rehabilitation level of care is required. The enrollee requires physical therapy for mobility, occupational therapy for remaining activities of daily living. The enrollee's medical conditions appear stable and he is participating in the treatments being provided. He had been able to function at an independent level. He has initial goalsat a wheelchair level of function and would be expected to be able to fully participate and benefit from the required intensity of an acute rehabilitation therapy program. The enrollee has therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet his rehabilitation needs.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 been met. Therefore, we decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A4465.You asked the Plan to pre-approve the compression stockings. You say that you require the stockings.The Plan denied your request. The Plan says the stockings are noncovered because they do not meet the statutory definition of a surgical dressing.The Plan must follow Medicare rules. The rules say that compression stockings described by code A4465 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A4465.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve upper partial dentures (D5213) and lower partial dentures (D5214).
You asked the Plan to pre-approve the dental services. You say that you have no upper teeth and you would like to be able to smile, talk right and eat and request consideration. The Plan denied your request. The Plan says the requested service is not a covered benefit.
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 pre-approve upper partial dentures (D5213) and lower partial dentures (D5214).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit 
You asked the Plan to waive the copayment for the urgent care visit and ED visit. You say that you should not be responsible for additional charges. The Plan denied your request. The Plan says based on Medicare billing criteria, the claims were billed 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 an $80 copayment for each emergency room visit and a $55 copayment for each urgent care provider visit. You have been asked to pay $135 for the urgent care visit and ED visit. $80 for the ED visit and $55 for the urgent care visit equals $135. 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 urgent care visit
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 endosteal implants (D6010), 2 custom fabricated abutments (D6057), and 2 abutment supported crowns (D6058).You asked the Plan to pre-approve the dental services. You say that you were advised in 2018 that the plan covered implants. You say that your wife went to an informational meeting in October 2019. You say that she specifically asked if implants would be covered in 2020. You also say that was advised implants would be covered in 2020.The Plan denied your request. The Plan says endosteal implants are not listed as covered services. The Plan says custom fabricated abutments are not listed as covered services. The Plan also says abutment supported crowns are not listed as 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 dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve2 endosteal implants (D6010), 2 custom fabricated abutments (D6057), and 2 abutment supported crowns (D6058).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care from August 29, 2019 through September 4,
2019.
You asked the Plan to pay for 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 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. It appears that the plan's contracted delegate was provided the records for this
admission and has failed to forward them to support the decision to deny based on no medical necessity.
Therefore, we decided that the Plan has to pay for inpatient hospital care from August 29, 2019 through
September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from November 11, 2019 through November 14, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on November 11, 2019 and discharged on November 14, 2019. You were asked to pay a $325 copayment per day from November 11, 2019 through November 13, 2019, days 1-3 of your inpatient hospital care. You were discharged on November 14, 2019 and there wasno copayment charge for the day of discharge. Per your contract there is a $325 copayment per day required for days 1-5. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care from November 11, 2019 through November 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation services from November 17, 2018 through November 18, 2019 provided by an in-network provider.You asked the Plan to waive the copayment for the observation services. You say that you were never released from the emergency room (ER). You state the observation room was overcrowded and was in the ER for less than 12 hours and released to go home the following morning. You stated that you never changed into hospital attire and stayed in your clothes.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received observation services from November 17, 2018 through November 18, 2019 provided by provider. You are asked to pay a $600 copayment for the in-network observation services. 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 observation services from November 17, 2018 through November 18, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inspire Therapy Device (surgical implantable device for
upper airway stimulator to treat severe ostructive sleep apnea).
You asked the Plan to pre-approve the Inspire Therapy Device. You say that you feel surgical intervention is
medically necessary for the enrollee and the enrollee is an excellent candidate. The Plan
denied your request. The Plan says this procedure is considered experimental and investigational and
considered not reasonable or necessary by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Inspire Therapy Device have not been met. Therefore, we decided that the Plan does not have
to pre-approve Inspire Therapy Device (surgical implantable device for upper airway stimulator to treat severe
ostructive sleep apnea).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient diagnostic test and eye exam provided on December 4, 2019.You asked the Plan to waive the copayments for the outpatient diagnostic test and eye exam. You say that you feel you should not be responsible for this cost sharing amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an outpatient diagnostic test and an eye exam on the date of service at issue in this appeal. The Plan states the correct copayments have applied per your contract with the Plan.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 $35 copayment for Outpatient diagnostic tests and a $15 copayment for each Medicare-covered eye exam. We looked at the file and Medicare rules. The file shows that you received an outpatient diagnostic test and an eye exam on December 4, 2019. You have been asked to pay a $35 copayment for the outpatient diagnostic test. The outpatient diagnostic test falls within the Outpatient diagnostic tests benefit category. You have also been asked to pay a $15 copayment for the Medicare-covered eye exam. This eye exam falls within the Vision care benefit category. This means that you have been asked to pay the correct amounts 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 forthe outpatient diagnostic test and eye exam provided on December 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from November 1, 2019 to November 8, 2019.You asked the Plan to pay forhome infusion therapy. You say that this is a valid code.The Plan denied your request. The Plan says this code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from November 1, 2019 to November 8, 2019.