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 August 18,
2019 through August 19, 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 enrollee had a negative troponin and a stable electrocardiogram in the emergency
department. Ongoing care included telemetry, serial troponin levels and an echocardiogram. Care provided to
the enrollee was observation level. There were no advance interventions or complex medical conditions. The
enrollee had stable vital signs and no complaints at the time of admission. Inpatient services were not supported
by the documentation.
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 August 18, 2019 through August
19, 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 November 8, 2019 through November 10, 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 care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. Inpatient services were not supported by the documentation. 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 November 8, 2019 through November 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rehabilitation provided from
November 1, 2019 through November 22, 2019.
You asked the Plan to waive the copayment for cardiac rehabilitation. You say that you were informed therapy
after surgery was completely covered. You say that you cannot pay $90 per week. 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 $20
copayment per day for Medicare-covered cardiac rehabilitation services.
You have been asked to pay a $20 copayment for each cardiac rehabilitation visit. The total amount you owe is
$140 ($20/visit x 7 visits = $140). 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 copayment for cardiac rehabilitation provided
from November 1, 2019 through November 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 24, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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 physician's services provided on October 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by an OON provider between
June 4, 2019 and August 15, 2019.
You asked the Plan to pay for the dental services. You say that your in-network dentist referred you to this
provider for these treatments. The Plan denied your request. The Plan says no prior authorization was requested
or approved for you to receive the services from an out-of-network provider.
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
covered when they are received by an OON provider. Therefore, we decided that the Plan does not have to pay
for the dental services provided by an OON provider between June 4, 2019 and August 15, 2019.
Your complaint about not being happy with your in-network provider is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (BRCA) provided out of network on August
28, 2019.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan
denied your request. The Plan says you did not have prior authorization for out of network testing.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The contract with the Plan says outpatient diagnostic testing may
require prior authorization. The provider in this case is not a network provider with the Plan. The Plan did not
pre-approve this testing. We found no exception that would require the Plan to pay for this testing. Therefore,
we decided that the Plan does not have to pay for genetic testing (BRCA) provided out of network on August
28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140) provided on
October 17, 2019.
You asked the Plan to reimburse you for the dental service. You say that the oral exam was not covered
because your dental benefits were exhausted after you received poor dental care from a previous provider. You
say that you have requested a reimbursement for those services. You also say that you expect a refund to you
and your plan and feel that the oral exam be covered once that happens. The Plan denied your request. The Plan
says the annual maximum of $1,000 was exhausted prior to receiving the oral exam. The Plan also says that
you are responsible for any remaining charges after the annual maximum has been exhausted.
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 annual maximum benefit of $1,000
has been exhausted.
Therefore, we decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140)
provided on October 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says the records show that a same or similar study was done already.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found there is lack of
documentation regarding the CT-guided ablation procedure mentioned in the records. This exam apparently
was done 1/23/20. If this indeed was the case it probably would be reasonable to assess the size and
enhancement characteristics of the ablated mass 2-3 months after the procedure but there is not enough (any)
information concerning the procedure that was done and the rationale for a followup scan at this time.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve CT scan of the abdomen.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 21, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on October 21,
2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99212) provided on November 8, 2019.
You asked the Plan to pay for CPT 99212. The Plan denied your request. The Plan says payment is included in
the global surgical payment.
The Plan must follow Medicare rules. Medicare rules say that payment for the above services are included in
the payment for the global surgical procedure.
We looked at the file and Medicare rules. The services in question were provided by the same provider who
provided the enrollee's surgery (CPT 15260) on October 23, 2019. The services were provided within the 90-
day global surgical period, and therefore are included in the payment for the surgical procedure. Based on this
information, we decided that Medicare rules for coverage of CPT 99212 have not been met. Therefore, we
decided that the Plan does not have to pay for the services (CPT 99212) provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 13, 2019  by a non-participating provider.
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 rendered by a non-participating provider without 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 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 December 13, 2019 by a non-participating provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June
3, 2019 to June 28, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the claim contains an invalid bill type per CMS
guidelines.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the claim has
been submitted with an inappropriate bill type for home health services. Therefore, we decided that the Plan
does not have to pay for the home health services provided to the enrollee from June 3, 2019 to June 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the service was unauthorized routine care.
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 in this appeal. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided  on July 11, 2019 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 services you received on August 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not
enrolled in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare
program.
We looked at the file and Medicare rules. The services in question were received from a provider who is not
enrolled in the Medicare program. 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 the services you
received on August 28, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home nursing care (S9123) provided on August 1, 2019
through September 27, 2019.
You asked the Plan to pay for the home nursing care. You say that you would like reconsideration as these
services were billed correctly. The Plan denied your request. The Plan says the appropriate G and Q codes were
missing on the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9123 is not supported in the record. Specifically, the claim submitted does not include
the required Q and G codes. Additionally, S codes are not valid for Medicare purposes. Based on this
information, we decided that Medicare rules for coverage of the home nursing care have not been met.
Therefore, we decided that the Plan does not have to pay for home nursing care (S9123) provided on August 1,
2019 through September 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tangential biopsy of skin provided on November 6, 2019.
You asked the Plan to waive the copayment for the tangential biopsy of skin. You say that you disagree with the charges. 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 $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $100 copayment for the tangential biopsy of skin. The tangential biopsy of skin falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 tangential biopsy of skin provided on November 6, 2019.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the comprehensive metabolic panel, the lipid panel, and the lipoprotein laboratory tests. We decided that the Plan does not have to waive the coinsurance for the remaining laboratory services.
You asked the Plan to waive the coinsurance for the various laboratory services. You say that there are not many services in town and you are used to going to this hospital. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the coinsurance for the comprehensive metabolic panel, the lipid panel, and the lipoprotein laboratory tests.
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 records show that the 20% coinsurance was not applied to the comprehensive metabolic panel, the lipid panel, and the lipoprotein laboratory tests.
The Plan says that you must pay a total of $31.92 for the comprehensive metabolic panel, the lipid panel, and the lipoprotein laboratory tests. Based on the plan contract, however, you cannot be asked to pay more than a total of $7.45 for comprehensive metabolic panel, the lipid panel, and the lipoprotein laboratory tests. Therefore, we decided that the Plan has to reduce the coinsurance for comprehensive metabolic panel, the lipid panel, and the lipoprotein laboratory tests from $31.92 to $7.45. 
We also decided that the Plan does not have to waive the coinsurance for the remaining laboratory services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% for the various laboratory services and a $35 copayment for the venipuncture. Therefore, we decided that the Plan does not have to waive the coinsurance for the remaining laboratory services. See chart below.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397)
provided to the enrollee on August 21, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with
suspension sleeve (L1851, L2397) provided to the enrollee on August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 12, 2019 through November 14, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were sent to the hospital because of the drops that were put into your eyes that caused you to lose consciousness. 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 shows that you were admitted on November 12, 2019 and discharged on November 14, 2019. You were asked to pay a $375 copayment per day from November 12, 2019 through November 13, 2019, days 1-2 of your inpatient hospital care. You were discharged on November 14, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $375 copayment per day required for days 1-4. 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 inpatient hospital care from November 12, 2019 through November 14, 2019.