Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve home health services. You say that continued services are medically necessary. The Plan denied your request. The Plan says you no longer require home health services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 home health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations, and you have informal support. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 11, 2021, through January 14, 2021.

You asked the Plan to waive the copayment for the inpatient stay. You say that you were transferred to another hospital and kept there until being discharged on January 29th. You say that you should not be responsible for the first bill. 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). Your contract with the Plan clearly says that you must pay a $350 copayment per day, for days 1-5 for each in-network, Medicare-covered hospital admission.

You have been asked to pay a $1,050 copayment for the inpatient stay. ($350/day x 3 days = $1,050). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show this was a separate inpatient admission. 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 inpatient stay provided from January 11, 2021, through January 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen you had on February 4, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you had the Coronavirus and were having gastro-related issues. You feel as though this cost sharing should be waived. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($207.19) is less than your copayment obligation, you are responsible for the full allowed 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 Medicare-covered diagnostic radiology services (except ultrasounds).
You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the Medicare-covered diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the abdomen you had on February 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Ultrasound, retroperitoneal, real time with image documentation provided on September 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that please review the enclosed records and process this claim for payment based on medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 Ultrasound, retroperitoneal, real time with image documentation provided on September 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on January 12, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician depends on the hospital staff to obtain the proper authorization. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 rest home visit provided on January 12, 2021 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two surgical placements of implant bodies: endosteal implants (D6010 x2) provided on February 18, 2021.
You asked the Plan to pay for the endosteal implants. You say that the implants are not cosmetic because you needed them. The Plan denied your request. The Plan says this procedure is not included in the benefits section of your EOC.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two surgical placements of implant bodies: endosteal implants (D6010 x2) provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram (EKG) provided on March 29, 2021.You asked the Plan to waive the copayment foran EKG. You say that the cost share is wrong.The Plandenied your request. The Plan says the cost share 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 thePlan clearly says that you must pay a $50 outpatient hospital diagnostic procedure and tests copayment for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $50 outpatient hospital diagnostic procedure and tests copayment for an EKG. This 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 foran electrocardiogram (EKG) provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care (99225) provided on April 3, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent observation care. You say that the enrollee was seen at an in-network facility and did not get to choose their provider. Please reprocess claim according to thee enrollee's in-network benefits and you will honor the contractual discount. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the subsequent observation care (99225) provided on April 3, 2021 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for infusion therapy services you received at an outpatient hospital facility on April 1, 2020, and April 14, 2020.
You asked the Plan to waive the copayments for the infusion therapy services. You say that these services have always been covered in full. The Plan denied your request. The Plan says you were charged these copayments 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 $370 copayment for services provided at an outpatient hospital facility.
Records show that you visited an outpatient hospital facility on April 1, 2020, and April 14, 2020, for infusion therapy services. Your Evidence of Coverage says that you pay a $370 copayment for each service at an outpatient hospital facility (including infusion therapy services). You have been asked to pay $208.65 for each of the two dates of service. This is because the allowed amount is less than your copayment responsibility. As a result, you are only being charged the allowed amount. 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 infusion therapy services you received at an outpatient hospital facility on April 1, 2020, and April 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425 A0429) received May 16, 2020.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance transportation was medically necessary, and you would like the copayment waived. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $260 copayment for Ambulance Services. 

You have been asked to pay a $260 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425 A0429) received May 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 11, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is no evidence of an established relationship between the enrollee and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on November 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for immunotherapy services provided on April 1, 2019, by a provider not enrolled in the Medicare program.
You asked the Plan to pay for immunotherapy services. You say that, per the Plan contract, prior authorization is not needed to obtain out of network services. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for immunotherapy services provided on April 1, 2019, by a provider not enrolled in the Medicare program.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram rendered on January 27, 2021.
You asked the Plan to waive the copayment for these services. You say that the copayment should be lower. 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 $125 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a freestanding facility. Review of the file shows that you received an echocardiogram on January 27, 2021. You have been asked to pay a $125 copayment for these services. These services fall within the Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a freestanding facility, 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 echocardiogram rendered on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on July 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 physician services provided on July 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic service provided on September 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for chiropractic service. You say that you developed severe pain so went to this provider where you had treatment previously. The Plan denied your request. The Plan says the denial of payment for this service 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 chiropractic service provided on September 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on June 11, 2020, to June 14, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment 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 $325 copayment for outpatient surgery/in-network/outpatient hospital. You have been asked to pay a $325 copayment for an outpatient surgery. The correct copayment has been
applied. An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on June 11, 2020, to June 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, fluid swing and stance phase control (L5828), stance flexion feature (L5845), fluid stance extension (L5848), microprocessor control feature, swing and stance phase, includes electronic sensor(s) (L5856), and above knee or hip disarticulation, knee extension assist (L5850).
You asked the Plan to pre-approve an endoskeletal knee-shin system, fluid swing and stance phase control, stance flexion feature, fluid stance extension, microprocessor control feature, swing and stance phase, includes electronic sensor(s), and above knee or hip disarticulation, knee extension assist. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a fluid, pneumatic, or electronic/microprocessor knee (L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or 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 an endoskeletal knee-shin system, fluid swing and stance phase control, stance flexion feature, fluid stance extension, microprocessor control feature, swing and stance phase, includes electronic sensor(s), and above knee or hip disarticulation, knee extension
assist. Our reviewer says that the items are not medically necessary. Our physician reviewer found the requested items exceed your medical need as the physician and documentation does not support that you are unable to use a mechanical K3 knee for your functional 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 an endoskeletal knee-shin system, fluid swing and stance phase control, stance flexion feature, fluid stance extension, microprocessor control feature, swing and stance phase, includes electronic sensor(s), and above knee or hip disarticulation, knee extension assist have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal knee-shin system, fluid swing and stance phase control (L5828), stance flexion feature (L5845), fluid stance extension (L5848), microprocessor control feature, swing and stance phase, includes electronic sensor(s) (L5856), and above knee or hip disarticulation, knee extension assist (L5850).