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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 18, 2019 through July 24, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were admitted to the emergency room with the inability to choose what providers service you. You state the claim should be processed in-network due to these circumstances. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 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 to an out-of-network provider on July 18, 2019 and discharged on July 24, 2019. You were asked to pay a $325 copayment per day from July 18, 2019 through July 22, 2019, days 1-5 of your inpatient hospital care. There were no copayment charges from July 23, 2019, day 6 of your inpatient hospital care until your day of discharge July 24, 2019. Per your contract there is a $360 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 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 from July 18, 2019 through July 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that the enrollee needs to learn how to take care of herself before being sent home. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds (CPT Code K0814) and the other requested items/accessories.
You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the scooter is 2 years old and has not reached the reasonable useful lifetime of 5 years and does not meet Medicare guidelines for replacement.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Plan approved and paid for a scooter and scooter repairs. You received a scooter in October 2017 and repairs were performed in 2018. The current scooter has not reached its reasonable and useful lifetime of 5 years and does not meet Medicare guidelines for replacement. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds (CPT Code K0814) and the other requested items/accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from May 2, 2019 through May 6, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that the enrollee never left the hospital. You say that there should be no charge for being readmitted. 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 $200 each time you are admitted to an acute care hospital. The enrollee has been asked to pay a $200 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that the enrollee was readmitted to inpatient status on May 2, 2019. 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 inpatient stay provided from May 2, 2019 through May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for testing services provided to the enrollee on September 12, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 testing services provided to the enrollee on September 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 26, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because they were unable to fully resolve your concern. 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 $90 copayment for emergency care. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $90 copayment for the emergency room visit.
You have been asked to pay a $56.03 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were evaluated and seen at the emergency room.
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 emergency room visit provided on October 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zytiga 250mg tablet (J8999).
You asked the Plan to pre-approve Zytiga 250mg tablet. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Zytiga 250mg tablet (J8999).
Benefits for Zytiga 250mg tablet 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 29, 2019 through June 30, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 29, 2019 through June 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by Zoll Medical Equipment on August 15, 2019. 
 
You asked the Plan to waive the coinsurance for a life vest. You say that you were never told that you would owe monthly for this. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a life vest. The allowed amount is $3,016. The total amount you are being asked to pay is $603.20 ($3,016 x 20% = $603.20). The correct coinsurance has been applied to the service that was provided to you. A life vest falls within the durable medical equipment 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 durable medical equipment provided by Zoll Medical Equipment on August 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on August 26, 2019.
You asked the Plan to pay for the mammogram. 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 mammogram provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have severe foot pain which makes it difficult for you to work. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to regain maximum function to return home. The Plan denied your request. The Plan says the clinicals do not indicate you being able to tolerate at least 3 hours of therapy a day.
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 out of bed activities required total assistance for safety with use of gait belt and rolling walker. You had poor balance and safety awareness. You required maximal assistance when scooting up in bed, and moderate assistance for lateral scooting. You were dependent when transitioning from seated to standing. You were seen for a swallowing evaluation without signs or symptoms of aspiration. You have multiple complex medical conditions. You have sternal precautions, and there would be an expected need to modify your treatment in order to maximize your capacity to benefit from rehabilitation. You require physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. However, you are limited by debility and the severity of your comorbid medical conditions. You are unable to fully participate in or benefit from the required intensity of an acute rehabilitation therapy 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-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.The Plan must follow Medicare rules.The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee, who subsequent to cerebral vascular accident, was transferred to IRF in August 2019 and then transferred to SNF for ongoing therapies. While there the enrollee became very depressed with suicidal ideation. The enrollee was transferred to a behavioral unit where he developed confusion with severe MS status changes. Admitted to acute careon 9/1/19 where he was diagnosed with altered mental status and vancomycin-resistant enterococcus urinary tract infection. The enrollee transferred to his current SNF on 12/27/19. His prior level of function was non-ambulatory and dependent with transfersand activities of daily living since July 2019. He resides in a long term care facility. His current level of function is dependent with bed mobility, dependent with transfers with mechanical lift, non-ambulatory, minimal assist with grooming, and maximalassist with toileting and dressing. Based on available records, the enrollee does not meet criteria for coverage of IRF. The enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or acute rehab nursing care. While he may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physicianoversight and an interdisciplinary approach to rehabilitation care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics (L3000). You say that the enrollee has medical conditions
causing ankle pain and their custom orthotics are worn out. The Plan denied your request. The Plan says this
item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that the enrollee does not suffer from diabetic foot disease and does not wear a shoe that is part
of a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides
coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot
orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the comprehensive oral evaluation, panoramic
x-ray, and complete series of intraoral x-rays provided on September 30, 2019.
You asked the Plan to waive the charges for the comprehensive oral evaluation, panoramic x-ray, and complete
series of intraoral x-rays. You say that you do not want to pay for these services because you did not get
reliable dental services that you can trust. The Plan denied your request. The Plan says the provider has the
right to bill for the services provided. The Plan also says that the claim was processed according to your plan
benefits.
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 were
paid appropriately according to your plan benefits. Therefore, we decided that the Plan does not have to waive
the charges for the comprehensive oral evaluation, panoramic x-ray, and complete series of intraoral x-rays
provided on September 30, 2019.
Your complaint about this operating practices of this provider is not a valid appeal for medical coverage. This
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratoryservices provided on June 13, 2019 by the out of network provider.You asked the Plan to pay forlaboratory services. You say that you were not aware the laboratory was not in network.The Plan denied your request. The Plan says you must use network providers to get your medical care and services.Medicare rules say that plans can requireenrollees 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 forlaboratory services provided on June 13, 2019 by the out of network provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that the enrollee has medical conditions causing foot pain and needs custom orthotics. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics