Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the CT scan and glucagon hydrochloride
injection provided on May 28, 2019.
You asked the Plan to waive the cost share for the CT scan and glucagon hydrochloride injection. You say that
you didn't receive the denial until October. You say that you are appealing the denial. The Plan denied your
request. The Plan says the cost share 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 $150
copayment for in-network CT scans and 20% coinsurance for in-network chemotherapy drugs and all other
drugs covered under Medicare Part B.
You have been asked to pay a total of $193.98 for the CT scan and glucagon hydrochloride injection.
Service Allowed Amount Standard Cost Share Member Liability
CT Scan $395.44 $150 $150
Glucagon Hydrochloride
Injection
$219.92 20% $43.98
TOTAL: $193.98
The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. The glucagon hydrochloride injection falls within the "Medicare Part B prescription drugs" 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 cost share for the CT scan and glucagon hydrochloride
injection provided on May 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 3, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on July 3, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the post and cores in addition to crowns for tooth #'s 6 & 7.
You asked the Plan to pre-approve the posts and cores. The Plan denied your request. The Plan says that a significant portion of the tooth is remaining, and a post is contraindicated. The Plan also says that the service is not medically necessary.
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. The Plan covers the posts and cores when the services are medically necessary and reasonable. 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 the posts and cores. Our reviewer says that the service is medically necessary. Our physician reviewer found that teeth #'s 6 and 7 meet the criteria for coverage for post and cores and crowns due to the significant breakdown of the coronal structure due to the endodontic access and previous caries and fracture. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the posts and cores have been met. Therefore, we decided that the Plan has to pre-approve the post and cores in addition to crowns for tooth #'s 6 & 7.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient hospital facility visit provided by THE CLINIC on December 11, 2019.You asked the Plan to waive the copayment foran outpatient hospital facility visit. You say that you disagree with the charges for just walking in the building.The Plan denied your request. The Plan says the claims were processed correctly,and you are being charged the correct 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 $400 copayment for outpatient hospital surgery services, a $125 copayment for observation services and a $20 copayment for all other outpatient hospital services. You have been asked to pay a $20 copayment for an outpatient hospital facility visit. An outpatient hospital facility visit falls within the outpatient hospital 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 thePlan does not have to waive the copayment foran outpatient hospital facility visit provided by THE CLINIC on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound care provided from July 2, 2019 through August 13, 2019.You asked the Plan to waive the copayments for wound care. You say that you never went to a hospital or an operating room. You say that the charges are out of line.The Plan denied your request. The Plan says the copayments 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 $325 copayment for each covered surgery or observation room service in an outpatient hospital and a $45 copayment for each covered specialist office visit. Wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" and "Physician/Practitioner services, including doctor's office visits" 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 copayments for wound care provided from July 2, 2019 through August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 21, 2019.You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the seat lift mechanism of the seat lift chair purchased on February 7, 2019.You asked the Plan to reimburse you forthe seat lift mechanism. You say that because of your hip you need the lift chair to be able to get up and down from a sitting position.The Plan denied your request. The Plan says the provider is not certified by MedicareThe Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of for the seat lift mechanism have not been met.The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you forthe seat lift mechanism of the seat lift chair purchased on February 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) and eye exam (92285) provided October 13, 2019.
You asked the Plan to pay for the vision services. You say that you feel that the charges should be covered because there is nowhere that says vision test provided by out of network providers are subject to an out of network deductible. The Plan denied your request. The Plan says the 98.74 was applied towards the deductible. Until you have paid the deductible amount, you must pay the full cost of the covered services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $500 deductible. Your deductible is $500. This is the amount you have to pay out-of-pocket before the plain will pay their share for covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible. This cost sharing is a contractual obligation that had not been met at the time the vision services was received on October 16, 2019. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) and eye exam (92285) provided October 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from July 13, 2019
through July 14, 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 July 13, 2019 through July 14,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount forthe porcelain crown (D2740) provided on July 11, 2019.You asked the Plan to pay the full amount forthe dental service. You say that you have never heard of the only in network provider in your area. You say that there has never been a coverage issue for preventive care that you received from your family dentist. You say that this was an emergency situation, "why should it be any different?" You also say that the 2019 Evidence of Coverage is quite ambiguous regarding this matter.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that for services received out of network there is a 50% coinsurance. The Plan also says the in network and out of network coinsurance for comprehensive dental services is the same, 50%.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 and crowns are listed as a covered service, there is a 50% coinsurance for non-Medicare covered comprehensive dental services. The record shows that the total billed amount was $1,200,  the Plan paid $600, and your responsibility is the remaining 50% coinsurance.Therefore, we decided that the Plan does not have to pay the full amount for the porcelain crown (D2740) provided on July 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you are a fall risk, and are not mobile without
assistance. The Plan denied your request. The Plan says you are at your baseline, and your needs are custodial.
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 services. Our physician reviewer
found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing
service needs. Regarding rehab services, you are at a supervision to independent level with functional mobility.
You require varying assist with activities of daily living. Although there are identifiable skilled therapy service
needs, you do not require skilled nursing or therapy services on a daily basis.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adjustable bed.
You asked the Plan to pre-approve a Serta Motion Series adjustable bed. You say that you need this to improve circulation and elevate your knee. The Plan denied your request. The Plan says that this is not covered and there is no physician order for a covered bed.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an adjustable bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on December 3, 2019.
You asked the Plan to pay for the hearing aids. You say that you obtained the hearing aids from an out-of-network provider because you did not know that there was a network of providers that you had to get services from. The Plan denied your request. The Plan says prior authorization was not obtained prior to receiving services from the non-contracted provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. For out-of-network services an authorization must be obtained prior to receiving the services. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for COPD and pneumonia. The enrollee was reportedly intubated/ventilated and apparently received a tracheotomy. The enrollee has been tolerating a tracheotomy mask and tracheotomy collar. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient stay, office visit, x-rays and cardiac rehabilitation provided from January 28, 2019 through July 5, 2019. 
 
You asked the Plan to waive the cost share for the inpatient stay, office visit, x-rays and cardiac rehabilitation. You say that you are unable to pay the amount you are being billed. You say that the bills should be waived. The Plan denied your request. The Plan says the cost share 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 $410 per day, days 1-4 for each in-network inpatient stay, 50% coinsurance for out-of-network primary care physician services, 50% coinsurance for out-of-network You have been asked to pay a total of $2,272.88 for the inpatient stay, office visit, x-rays and cardiac rehabilitation.  
 
Date of Service Service Allowed Amount Standard Cost Member Liability January 28, 2019- February 4, 2019 Inpatient Stay $23,104.31 $410/day $1,640 February 19, 2019 Office Visit $170.82 50% $85.41 February 19, 2019 Upper GI X-Ray $36.59 50% $18.29 February 19, 2019 Swallow Imaging $28.09 50% $14.04 February 19, 2019 Neck/Spine X-Ray $11.83 50% $5.91 February 19, 2019 Neck X-Ray $8.86 50% $4.43 February 19, 2019 Jaw X-Ray $9.61 50% $4.80 June 10, 2019- July 5, 2019 Cardiac Rehabilitation $1,140.20 $50/visit $500 TOTAL:    $2,272.88 
 
The inpatient stay falls within the "Inpatient hospital care" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The cardiac rehabilitation falls within the "Cardiac rehabilitation 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 cost share for the inpatient stay, office visit, x-rays and cardiac rehabilitation provided from January 28, 2019 through July 5, 2019.x-rays and a $50 copayment for in-network, Medicare-covered cardiac rehabilitation and intensive cardiac rehabilitation services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 18, 2019 through September 24, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that he record did 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. The hospital services September 18, 2019 through September 24, 2019 were medically necessary and reasonable. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 18, 2019 through September 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for yogurt and Saw Palmetto purchased on August 9, 2019.
You asked the Plan to reimburse you for the yogurt and Saw Palmetto. You say that the Saw Palmetto was recommended for you by your doctor. The Plan denied your request. The Plan says yogurt and Saw Palmetto are not listed as OTC catalog items that the Plan covers.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the Plan offers an OTC benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan only covers OTC items listed in the Plan's OTC catalog.
We looked at the file and the Plan's rules. The file shows that yogurt and Saw Palmetto are not listed as OTC catalog items. Therefore, we decided that the Plan does not have to reimburse you for yogurt and Saw Palmetto purchased on August 9, 2019.