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

We decided that the Plan does not have to waive the copayment for the x-ray rendered on April 27, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $10 copayment for each basic imaging service (e.g. general x-rays or ultrasound).

Review of the file shows that you received an x-ray on April 27, 2021. You have been asked to pay a $10 copayment for these services. These services fall within the basic imaging service (e.g. general x-rays or ultrasound) 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 rendered on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayments for the intravenous infusion, for therapy, prophylaxis, or diagnosis (96365) and the therapeutic, prophylactic, or diagnostic injection (96374) provided from November 7, 2020, through November 17, 2020.
You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $280 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $2,163.70 ($188.37 copayment x 11=$2,072.07 + $91.63 physician charges) for the Medicare-covered services provided to you at an outpatient hospital. This is the Plan's allowed amount for these services which is less than the applicable copayments. 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 adjust the copayments for the intravenous infusion, for therapy, prophylaxis, or diagnosis (96365) and the therapeutic, prophylactic, or diagnostic injection (96374) provided from November 7, 2020, through November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the urology services provided on December 23, 2020 by an out-of-network provider.
You asked the Plan to pay for the urology services. You say that you would like the Plan to consider payment based on medical necessity. The Plan denied your request. The Plan says you did not request 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 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 for the urology services provided on December 23, 2020 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require daily skilled therapy services on an inpatient basis. Activities of daily living (ADLs) assist can be provided by an unskilled attendant and does not require skills of a therapist. The SNF admission is not reasonable and medically necessary for the enrollee's condition. 

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 Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99231) provided February 11, 2021.
You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan
denied your request. The Plan says the service billed is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99231
has a column I / column II relationship with code 01638 and cannot be paid as billed. This code cannot be paid
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for hospital care (99231) provided February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient surgical services, radiology services, and office visit rendered on August 19, 2020 to October 29, 2020.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost sharing was 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 $200 copayment for complex radiology (MRI), a $45 copayment for routine radiology (x-ray), a $350 copayment for outpatient surgery at an outpatient hospital facility, pay a $15 copayment for PCP visits received from a standard primary care physician, and a $45 copayment for specialist services.
Review of the file shows that you received an MRI on August 19, 2020. You have been asked to pay a $200 copayment for these services. These services fall within the complex radiology (MRI) benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received specialist services on September 30, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the specialist services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received a PCP office visit on October 9, 2020. You have been asked to pay a $15 copayment for these services. These services fall within the PCP visits received from a standard primary care physician benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received an x-ray on October 23, 2020. You have been asked to pay a $45 copayment for these services. These services fall within the routine radiology (x-ray) benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received an outpatient surgical procedure to your fingers on October 29, 2020. Per the contract with the Plan, there is a $350 copayment for outpatient surgery at an outpatient hospital facility. However, the Medicare allowed amount for these services was $219.16. Given that the allowed amount was less than the $350 copayment, you have been asked to pay $219.16 for these services.
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 cost sharing for the outpatient surgical services, radiology services, and office visit rendered on August 19, 2020 to October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health care.
You asked the Plan to pre-approve inpatient behavioral health care. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
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 pre-approve inpatient behavioral health care. Our
reviewer says that the services are not medically necessary.
Our physician reviewer found based upon review of the records provided, the admission of this enrollee does
not meet the criteria for continued acute inpatient mental health treatment for the dates in question of August 9,
2021 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any
auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing
any aggressive behaviors, or any treatment required for acute threats of safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient behavioral health care have not been met. Therefore, we decided that
the Plan does not have to pre-approve inpatient behavioral health care.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a negative pressure wound therapy pump with supplies provided on December 1, 2020.

You asked the Plan to waive the coinsurance for wound therapy pump and supplies. You say that you were told everything would be paid for by your insurance. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

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 in-network wound therapy pump and supplies. The allowed amount of the claim is $1,721.81, resulting in a coinsurance amount of $344.36.

You have been asked to pay 20% coinsurance for wound therapy pump and supplies. Wound therapy pump and supplies fall within the Durable Medical Equipment and Related 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 coinsurance for a negative pressure wound therapy pump with supplies provided on December 1, 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 IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that based on review of available records, the enrollee does not meet the criteria for coverage for an IRF admission. Based on the enrollee's current medical stability and lack of medical complexity, there is no need for physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented acute rehab nursing needs. Functionally as described above at that level, there is no evidence of indication for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The guidelines require that the patient should make a significant progress in a reasonable and predicted period of time in an IRF. The enrollee is deconditioned and has very little progress in 3 weeks' time and will not attain significant change in function with admission to an IRF. IRF admission is not medically necessary based on lack of medical complexity or identified rehab nursing needs for an enrollee with debility. The enrollee's rehab needs can be easily and safely met at a less intense and alternate level of setting such as in an skilled nursing facility.

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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you were admitted for a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from the 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to approve separate payment for Epoetin Beta.
You asked the Plan to approve separate payment for Epoetin Beta. You say that this is medically necessary. The Plan denied your request. The Plan says that the requested drug should be billed to Medicare Part B bundled payment by the dialysis facility.
The Plan must follow Medicare rules. Medicare rules say that ESRD facilities are responsible for furnishing drugs directly or under arrangement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Epoetin Beta have not been met.
Please note: Our determination is the need for separate payment only. We are making no determination as to the medical necessity of the requested drug, only that it must be provided by the ESRD facility directly or through arrangements and will be included in the composite rate paid to the facility. Therefore, we decided that the Plan does not have to approve separate payment for Epoetin Beta.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the advanced life support (ALS) routine disposable supplies (D0398) and the ambulance response and treatment, no transport, (A0998) provided on May 3, 2021.
You asked the Plan to pay for the ambulance services. You say that the individuals that came to your home refused to transport you to the hospital. You say that you did not refuse treatment. You say that you continued to have symptoms after the ambulance left and had to drive yourself to urgent care. You also say that you were transferred from the urgent care to the hospital. The Plan denied your request. The Plan says the provided documentation indicates that you refused transportation to the emergency room for further evaluation.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 3, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Additionally, the record shows that you specifically requested evaluation only. The record also shows that you were advised of and understood all risks and consequences of refusal and a signed Against Medical Advice document was obtained by the provider. Therefore, we decided that the Plan does not have to pay for the advanced life support (ALS) routine disposable supplies (D0398) and the ambulance response and treatment, no transport, (A0998) provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit and lab test provided on April 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for clinic visit and lab test. You say that you are requesting an appeal. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 had network providers available who could have provided 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 a clinic visit and lab test provided on April 2, 2021
by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the psychotherapy (90834) provided from December 9, 2020, through December 30, 2020.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 each Medicare-covered outpatient mental health individual therapy session.
You have been asked to pay $120 ($40 copayment x 3) for the Medicare-covered outpatient mental health individual therapy sessions provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the psychotherapy (90834) provided from December 9, 2020, through December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dental anesthesia services provided to the enrollee on March
26, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental anesthesia services
provided to the enrollee on March 26, 2021.