Persius/hicric huggingface dataset:
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 14, 2019 through June 15, 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 14, 2019 through June 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from July 19, 2019 through August 4, 2019.You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the member was not receiving and had no medical need for daily skilled services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from July 19, 2019 through August 4, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an eye exam provided on July 8, 2019 and August 8, 2019.You asked the Plan to pay for the physician's services for an eye exam. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to payfor physician's services for an eye exam provided on July 8, 2019 and August 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90833, 99213) provided April 8 to August 7, 2019.You asked the Plan to pay for the outpatient mental health services. You say that the services were reimbursed by your insurer in the past.The Plan denied your request. The Plan says the provider at issue does not participate in the Medicare program and cannot be issued payment.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90833, 99213) provided April 8 to August 7, 2019 .
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the medical/surgical supplies and the pharmacy services. We decided that the Plan does not have to reduce the coinsurance for the RFA procedure and the x-ray.
You asked the Plan to reduce the coinsurance for the radio frequency ablation (RFA) procedure, the x-ray, the medical/surgical supplies and the pharmacy services. You say that you were told the out-of-pocket cost would be a $295 copayment. You say you would like the plan to reduce your cost share amount to $295. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to waive the coinsurance for the medical/surgical supplies and the pharmacy services.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There was no Explanation of Benefit or claim form submitted with the codes at issue to verify the billed medical/surgical supplies and the pharmacy services.
The Plan says that you must pay a total of $850.40 for medical/surgical supplies and the pharmacy services. Based on the plan contract, however, you cannot be asked to pay more than $0 for services. Therefore, we decided that the Plan has to reduce the coinsurance for medical/surgical supplies and the pharmacy services from $850.40 to $0.
We also decided that the Plan does not have to reduce the coinsurance for the RFA procedure and the x-ray.
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 30% coinsurance for the RFA procedure and the x-ray. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
June 20, 2019
RFA procedure
$2,275.20
30%
$682.56
June 20, 2019
X-ray
$313.60
30%
$94.08
Total
$776.64
Therefore, we decided that the Plan does not have to reduce the coinsurance for the RFA procedure and the x-ray.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge provided on June 11, 2019 by out of network provider.You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says a Plan provider did not refer the enrollee for the services. The Plan also says the services provided were not urgent or emergent.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The ordering physician is not a network provider either. 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 observation care discharge provided on June 11, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services provided to the enrollee.
You asked the Plan to pay for the occupational therapy services. The Plan denied your request. The Plan says the services did not require the skills of a therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the occupational therapy services. Our physician reviewer found that per medical records OT was requested to maintain passive range of motion (PROM) of the bilateral upper extremities to prevent contractures, and preserve skin integrity. OT goals were to tolerate gentle PROM. The enrollee was noted not to tolerate wearing in left hand at all times. She tenses up and is resistive. She is guarded with ROM right shoulder. A rolled towel was recommended inside a pillow case. The enrollee and caregiver trained in splinting and orthotic schedule. The documentation does not reveal that the services were generally effective for the enrollee's condition, and that the unique skills of a professional therapist were required to perform the services. The specialized skill of a qualified therapist was not required during this time to design/deliver a program to maintain the enrollee's current condition, or prevent/slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the occupational therapy services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided.
You asked the Plan to pay for drug tests. You say that you had every reason to believe that the treating physician's order of these tests would establish medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the billed diagnosis code of F31.5 is not a covered diagnosis for these tests.
The Plan must follow Medicare rules. Medicare rules say that diagnosis code F31.5 is not a covered diagnosis for procedure codes 80307 and G0480. We looked at the file and Medicare rules. These tests are not covered by Medicare when billed with diagnosis code F31.5. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for anabolic steroids provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. 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. In this case, the CPT Code Manual definition of code 80327 is "Anabolic steroids; 1 or 2." We find that CPT code 80327 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for anabolic steroids provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the urography rendered on August 6, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were previously paid to a same or different provider.The Plan must follow Medicare rules. The rules say that the PC of a radiology services is paid separately only if rendered by a different provider or in a different payment locality than the TC.We looked at the file and Medicare rules. The file does not show that the PC for code 74420 (urography) for the date of service at issue was performed by a different provider or in a different payment locality than the TC. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the urography rendered on August 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3 rest home visits, and the annual wellness visit provided by the out of network provider.
You asked the Plan to pay for the practitioner services. You say that the enrollee does not have the option to choose which provider they see. You say that the providers are covered by the authorization obtained by the facility. You also say that the rendering facility is in network. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee was referred for the services by another non-participating provider. The Plan also says there was no evidence provided to show that the services were urgent or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The referring physician is not a network provider. The rendering facility is not a network provider either. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the 3 rest home visits, and the annual wellness visit provided by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by out of network provider.
You asked the Plan to pay for lab test. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for this service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received.
You asked the Plan to pay for the services. You say that the pain was not from the accident. The Plan denied your request. The Plan says the services were related to a motor vehicle accident.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified that the automobile insurance is the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services you received.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 15, 2019 to August 5, 2019 by out of network provider.You asked the Plan to pay for chiropractic services. You say that you were not getting anywhere with the in-network provider. You say that you are getting results.The Plan denied your request. The Plan says there are in-network providers who can provide 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 15, 2019 to August 5, 2019 by out of network provider.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to waive the cost share for the nerve stimulator generator. We decided that the Plan does not have to waive the cost share for the implant pain device surgery. You asked the Plan to waive the cost share forthe nerve stimulator generator. You say that you were told there would be no additional charges for the surgery. The Plan says that you have been charged the correct cost sharing amount
We decided that the Plan has to waive the cost share for the nerve stimulator generator. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The contract says there is no charge for surgically implanted internal prosthetic devices. The records show that the nerve stimulator generator code is considered a prosthetic device.  The Plan says that you must pay $5,240 for the nerve stimulator generator. Based on the plan contract, however, you cannot be asked to pay more than $0for the nerve stimulator generator. Therefore, we decided that the Plan has to reduce the cost sharefor the nerve stimulator generator from $5,240 to $0. We also decided that the Plan does not have to waive the cost share for the implant pain device surgery.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 outpatient surgery.Therefore, we decided that the Plan does not have to waive the cost share for the implant pain device surgery.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit with a specialist provided by the provider on September 3, 2019.You asked the Plan to waive the copayment foranoffice visit. You say that you shouldn't be responsible for this extra copay.You saythat you never had to pay for this before. You say the provider is double charging you.The Plan denied your request. The Plan says physician services with a specialist have a $20 copayment.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 copayment for physician services. You have been asked to pay a $20 copayment for an office visitwith a specialist. This servicefalls within the physician 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 foran office visit with a specialist provided on September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the provider  from August 11, 2019 to October 30, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that The Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the provider from August 11, 2019 to October 30, 2019.