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

We decided that the Plan does not have to waive the cost-share for acute inpatient rehab services provided by an out-of-network provider from May 21, 2019 through May 30, 2019.
You asked the Plan to waive the cost-share for acute inpatient rehab services. You say that you were never informed of the provider being out-of-network. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received acute inpatient rehab services provided b an out-of-network provided from May 21, 2019 through May 30, 2019. Your EOC clearly states, after you pay your $700 deductible, you pay: 30% per stay for each out-of-network medically necessary covered inpatient stay. However, the plan charged you 25% coinsurance instead of the 30% coinsurance; therefore, the cost-share is less than it would be with 30% coinsurance. 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 acute inpatient rehab services provided by an out-of-network provider from May 21, 2019 through May 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting, such as home, a long-term care facility, or other outpatient setting.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) and shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 7, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the documentation indicates services are not necessary for treatment of the enrollee's condition.
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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible physical examination of the shoulder. The Musculoskeletal exam is limited to "Visual overview of all four extremities is normal."
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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) and shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on July 16, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is no valid referral 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 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 nurse practitioner services provided on July 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80307 and G0483) provided on June
27, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, 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. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services (80307 and G0483) provided on June 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from July 6, 2019 through August 4, 2019.
You asked the Plan to pay for SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from July 6, 2019 through August 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services provided on September 4, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford the facility charge because you are only on Social Security. You state you are not in charge of the doctor nor where they see you, and there is only one transplant center. You state you should not have a facility fee every time she sees the doctor. She never had to pay this fee in the past three years. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received services provided on September 4, 2019. Your EOC clearly states, when you visit a provider, you may be charged a "facility fee." This fee reflects a trend in hospitals buying doctors' practices and adding "facility fees" to patient bills. In those cases, the outpatient cost-share applies to the services (see below for cost-share information). You should ask every provider's office you visit if you will be charged a facility fee and if there is another office where you can see the provider without paying the fee. Furthermore, enrollees pay a $325 copayment for each Medicare-covered non-surgical visit in an outpatient clinic. Therefore, since the Medicare allowable amount is less than the outpatient clinic copayment you are responsible for the lesser 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 copayment for the services provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided by on June 5,
2019.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual exam. You
say that you should not have a copayment. 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 $45
copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $45 copayment for the office visit. The office visit falls within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the
office visit was for postmenopausal atrophic vaginitis and a blood fecal test. 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 office visit provided by on June 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says that you do not meet criteria for these services.
The Plan follows Medicare rules. Medicare rules say that facet injections are covered when specific criteria are met. 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 these services. Our reviewer says that facet joint injections are not medically reasonable and necessary in this case. You have low back pain, which does not radiate. The pain started in approximately 2007 and is of unknown etiology. The pain is characterized as sharp and achy and is decreased when taking medications. Daily activity is improved with the medications without side effects. This appeal is for facet joint intervention for pain management. Although there is documentation of physical therapy in the past, documentation of the start and end dates for failure of conservative treatment were not provided. Our physician reviewer found that your condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from November 30, 2018 through December 1, 2018.
You asked the Plan to pay for 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 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 member's primary insurance plan will first need to process the claim in their system before the Plan can make payment. The Plan states they have contacted the primary carrier and the primary carrier confirmed they have no claim on file for this date of service; therefore, the Plan is unable to make payment at this time. As the secondary insurer, the Plan cannot be held responsible for inpatient hospital care until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from November 30, 2018 through December 1, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necesasry. The Plan denied your request. The Plan says there is no need demonstrated for a non-invasive ventilator, as there is no evidence that supplemental oxygen is not sufficient to treat any hypoxia present, and there is no evidence that you are currently hypercapneic at baseline.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found there are no medical records available for review. According to the provided case notes, you have COPD, with arterial blood gases during an acute hospitalization in November showing hypercarbia. There is a statement that you have failed BiPAP and CPAP because of claustrophobia, but there is no documentation of BiPAP failure while in a stable state (continued hypoxemia or worsening hypercarbia despite optimal BiPAP settings and supplemental O2). Moreover, your intolerance to the noninvasive interface makes it likely that you will not be able to tolerate a ventilator with a noninvasive interface. A home ventilator is therefore considered not medically necessary. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered to you on August 19, 2019.
You asked the Plan to waive the copayment for these services. You say that the provider told you there would be no copayment. 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 $50 copayment for each specialist visit for Medicare-covered services.
Review of the file shows that you received specialist services on August 19, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the specialist visit for Medicare-covered 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. The Plan cannot be held responsible for possible misinformation given by a provider regarding your cost sharing information. Therefore, we decided that the Plan does not have to waive the copayment for the physician services rendered to you by your doctor on August 19, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve Myocardial Perfusion Imaging (MPI).
You asked the Plan to pre-approve Myocardial Perfusion Imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee is medically stable with no complaints of chest pain, changes in heart rhythm or activity restrictions.
The Plan follows Medicare rules. Medicare rules say that this testing is covered when used for risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years. 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 Myocardial Perfusion Imaging. Our reviewer says that the coverage criteria for nuclear stress testing has been met. Our physician reviewer found the patient has not had a revascularization procedure in the prior 2 years and the test is requested "for risk assessment or re-evaluation of disease for a patient who is asymptomatic or has stable symptoms, with known atherosclerotic heart disease on catheterization." We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Myocardial Perfusion Imaging have been met. Therefore, we decided that the Plan has to pre-approve Myocardial Perfusion Imaging (MPI).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from July 30, 2019 to October 18, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). 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 the glucose
monitor, test strips, lancets, control solution, and lancet device provided from July
30, 2019 to October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe physician services rendered to you by "the doctor" on April 25, 2019 to July 22, 2019.You asked the Plan to waive the deductible forthese services. You say that you assumed the provider was in-network.The Plan denied your request. The Plan says the deductible was applied correctly.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 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the out-of-network physician specialist benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on April 25, 2019 to July 22, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe physician services rendered to you by "the doctor" on April 25, 2019 to July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 6, 2019 by the out of
network provider.
You asked the Plan to pay for physician services. You say that prior authorization is not required for the
services that were provided. The Plan denied your request. The Plan says the referring doctor is out-of-network.
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 May 6, 2019 by the
out of network provider.