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

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on June 25, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that the colonoscopy is a preventive service and should be fully covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $325 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows diagnosis codes for a personal history or colonic polyps and polyp of colon. Therefore, the colonoscopy is considered diagnostic in nature. 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 colonoscopy provided on June 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit at the Medical Center on September 18, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that the dentist's office was closed so you had to go to the ER and 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ER visit the Medical Center on September 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on September 5, 2019.
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. 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 $325 copayment for outpatient surgery at an outpatient hospital facility.
Review of the file shows that you received outpatient surgical services on September 5, 2019. You have been asked to pay a $325 copayment for these services. These services fall within the outpatient surgery at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the gene expression analysis test provided on August 8, 2019.
You asked the Plan to waive the coinsurance for the gene expression analysis test. You say that you were told you would have $0 liability for the testing. You say you do not feel you should be held responsible. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% coinsurance for molecular and predisposed genetic testing. You have been asked to pay $640, which is 20% of the allowed amount for the gene expression analysis test. The allowed amount is $3,200. ($3,200 x 20% = $640). The gene expression analysis test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the gene expression analysis test provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 3, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was for a physical exam. You
say that there should be no 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $20 copayment for each office visit to your provider of choice.
The enrollee has been asked to pay a $20 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 also a follow up for ongoing medical issues. This means that the enrollee has been asked to pay
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the office visit provided on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNon-Elastic Nighttime Extremity Binders identified with code A4465.You asked the Plan to pre-approveNon-Elastic Nighttime Extremity Binders. You say that you have a lot of swelling in your arms.The Plan denied your request. The Plan says that this is not a Medicare covered benefit.The Plan must follow Medicare rules. The rules say that Non-elastic binders for an extremity described by code A4465 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approveNon-Elastic Nighttime Extremity Binders identified with code A4465.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgical services provided on September 12, 2019 by the out of network provider.
You asked the Plan to pay for outpatient surgical services. You say that there was not time to get authorization. The Plan denied your request. The Plan says out-of-network services require 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 outpatient surgical services provided on September 12, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the neck spine.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that the provider must show a medical need before these tests can be approved.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found while you have a normal neurological exam with no red flags to mandate immediate MRI scan she does have progressive symptoms including loss of upper extremity sensation and decreased range of motion. Had there been no history of prior cervical fusion it would be reasonable to deny the requested MRI prior to a 6 week trial of PT. However, in this case there is history of prior cervical fusion and plain x-rays confirm degenerative changes below the cervical fusion and the patient seems unable to complete a trial of PT due to pain. Thus, it is reasonable to approve the requested MRI of the cervical spine even without a trial of PT. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the neck spine.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services required can be provided at a SNF level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of need for supervision by acute PMR or acute rehab nursing care. The enrollee may benefit from further PT and an OT but does not require an intensive therapy program. IRF admission is not medically necessary based on current functional status and medical stability. His rehab needs can easily be met in an SNF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay foran ophthalmoscopy (special eye examination) provided by "the doctor" on August 17, 2019.You asked the Plan topay forophthalmoscopy. You say that you are entitled to reimbursement, and are submitting the diagnosis codes for review.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this service is not covered by Medicare for these diagnoses.The Plan must follow Medicare rules. Medicare rules say that ophthalmoscopy is only covered by Medicare for certain specific diagnosis codes, including diagnosis code H35.373.We looked at the file and Medicare rules. You submitted a sheet from the treating provider showing the diagnosis codes for this service. Diagnosis code H35.373 is among those for which this ophthalmoscopy was provided. Based on this information, we decided that Medicare rules for coverageof ophthalmoscopy have been met.Therefore, we decided that the Plan has to pay foran ophthalmoscopy (special eye examination) provided by "the doctor" on August 17, 2019.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 toopen the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the record
does not show that the enrollee requires daily skilled nursing or daily skilled therapy in a SNF 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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on November 29, 2018.
You asked the Plan to waive the copayment for lab services. 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab services provided on November 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on October 11, 2018.You asked the Plan to pay fortrain of four testing. You say that this should be paid.The Plan denied your request. The Plan says this service is bundled into the payment of the primary service.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 95999 is not supported in the medical record. Specifically the use of unlisted CPT code 95999 to support train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on October 11, 2018.
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 16, 2019
through June 18, 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 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 16, 2019 through June 18,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral leg great saphenous vein ablation, varithena
ablation, and bilateral leg sclerotherapy for the enrollee.
You asked the Plan to pre-approve bilateral leg great saphenous vein ablation, varithena ablation, and bilateral
leg sclerotherapy. You say that you would like the plan to reconsider their denial. The Plan denied your
request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the treatment of varicose veins is only covered for
certain indications.
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 bilateral leg great saphenous vein
ablation, varithena ablation, and bilateral leg sclerotherapy. Our reviewer says that the documentation does not
support that the requested services are medically reasonable or necessary. Our physician reviewer found the
enrollee has bilateral lower extremity varicose veins. The documentation does not support complete
documentation that this enrollee has a diagnosis, condition, and/or symptoms that meet the Medicare criteria
for coverage of bilateral leg great saphenous vein ablation, Varithena ablation, and bilateral leg sclerotherapy.
Therefore, the enrollee does not meet criteria for the requested 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 bilateral leg great saphenous vein ablation, varithena ablation, and bilateral leg
sclerotherapy have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral leg
great saphenous vein ablation, varithena ablation, and bilateral leg sclerotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on June 14, 2019.You asked the Plan to waive the copayment forthe office visit. You say that no services were provided. You say that your responsibility should be $0.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 costsharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each Medicare-covered specialist visit.You have been asked to pay a $30 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 you were examined, the magnetic resonance imaging reports were reviewed and you received a referral during the office visit. 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 haveto waive the copayment forthe office visit provided on June 14, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forophthalmological medical examination and evaluation providedfrom March 27, 2019 through August 22, 2019.You asked the Plan to pay forthe ophthalmological medical examination and evaluation. You say that you required an eye examination every three weeks for an eye condition.The Plan denied your request. The Plan says that you have exhausted the yearly eye examination services. Medicare generally does not cover routine visionservices. The Plan covers outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.We looked at the file and the Plan's rules. The file shows that the services provided were for the diagnosisof endothelial corneal dystrophy, which is a Medicare-covered disease or condition of the eye. The services were not for a routine eye examination.Based on this information, we decided that the Plan's rules for coverage of the ophthalmological medical examination and evaluation have been met.Therefore, we decided that the Plan has to pay forthe ophthalmological medical examination and evaluation provided fromMarch 27, 2019 through August 22, 2019.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.