Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) received on June 13, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you should not be responsible for this copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 each ambulance trip. You had 1 ambulance trip on June 13, 2020. The Plan charged you $150 for these services. 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 ambulance services (A0429) received on June 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is 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 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 complexity of the patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for right foot pain and had an embolectomy for vascular disease. Medical problems are stable. There
are no identified problems that need inpatient medical management. There are no complex nursing or
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports
a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation
therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.
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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed. You asked the Plan to pre-approve a total electric hospital bed. You say that it would be beneficial for your caregivers to be able to elevate and lower you. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan. The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of
chiropractic care as the records provided do not demonstrate a subluxation of the spine.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this service have not been met. Specifically, the record does not show that the enrollee has a
subluxation of the spine demonstrated by x-ray or physical exam. Therefore, we decided that the Plan does not
have to pre-approve chiropractic manipulative treatment (98940).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from May 21, 2020, to June 2, 2020.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you would like the benefits to be combined into one visit.The Plan denied your request. The Plan says the copayment applied correctly in this case.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 per day (days 1-5) and a $0 copayment per day (days 6-90) for inpatient hospital care. You have been asked to pay a $325 copayment per day (days 1-5) and a $0 copayment per day (days 6-90) for the inpatient hospital stay for a total balance of $1625. The services provided fall within the inpatient hospital 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 forthe inpatient hospital stay provided from May 21, 2020, to June 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forarthrocentesis provided on June 23, 2020.You asked the Plan to waive the copayment forarthrocentesis. You say that you feel that the charges are too high.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 discloseto 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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. You have been asked to pay a $275 copayment for arthrocentesis. Arthrocentesis 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 forarthrocentesis provided on June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe inpatient mental health care you received  from an out-of-network hospital.You asked the Plan to waive the coinsurance forthe out-of-network inpatient mental health services. You say that you were not admitted to this hospital voluntarily, so you should not have to pay this coinsurance.The Plan denied your request. The Plan says this coinsurance 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 40% coinsurance for out-of-network inpatient mental health care. You have been asked to pay 40% coinsurance for the inpatient mental health services at an out-of-network facility. 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 forthe inpatient mental health care you received  from an out-of-network hospital.Your complaint about being involuntarily admitted to the facility and not being told whyis 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient appears to be improving, however, they require additional short-term acute care services of less than 25 days to further stabilize and complete treatment which can safely take place in the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from November 1, 2019 through November 27, 2019.You asked the Plan to waive the copayment forthe SNF stay. 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 $0 copayment each day for days 1 to 20 and a $160 copayment each day for days 21 to 62.You have been asked to pay a $$3,680 copayment for the SNF stay The SNF stay falls within the "Skilled Nursing Facility (SNF) 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 forthe SNF stay provided from November 1, 2019 through November 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on July 13, 2020.You asked the Plan to waive the copayment for a cortisone shot. You say that this was just a cortisone shot at a specialist's office. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery. You have been asked to pay a $150 copayment for a cortisone shot. The services that you received are consideredan outpatient surgery; therefore, the correct copayment has been applied. A cortisone shot falls within the outpatient surgery 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 outpatient surgery provided by a participating provider on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are
medically necessary. The Plan denied your request. The Plan says that the records received show that your
condition has improved and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is
not expected you will improve in a reasonable period of time. You do not have any suicidal or homicidal
thoughts, hallucinations or aggressive behaviors. You do not require inpatient mental health treatment as you
are not a danger to yourself or others and do not have any auditory or visual hallucinations or behavioral issues.
Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric
hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pay forperiodontal maintenance provided on June 29, 2020.You asked the Plan to pay forthe periodontal maintenance. You say that the service you received was a general cleaning. You say that payment of the cleaning should be reconsidered.The Plan denied your request. The Plan says the services are not covered benefits.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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forperiodontal maintenance provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit you had with an ophthalmologist on January 9, 2020.You asked the Plan to waive the copayment forthe ophthalmology visit. You say that you should have only been charged a $15 copayment for an annual routine eye exam.The Plan denied your request. The Plan says you did not have an annual routine eye exam.  The records show that your eye doctor billed for a follow-up visit related to your glaucoma condition.  Since this was not a routine eye exam, the specialist copayment applied correctly.The rules say a plan must disclose toits 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 outpatient visits for services to diagnose and/or treat adisease or condition of the eye. You have been asked to pay a $45 copayment for the ophthalmology visit. The ophthalmology visit falls within the outpatient visits for services to diagnose and/or treat a disease or condition of the eye 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 waivethe copayment forthe office visit you had with an ophthalmologist on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on August 19, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided .You asked the Plan to waive the copayment forphysical therapy. You say that you don't recall being seen on that date. You say that you only spoke to the office and declined further treatment.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 $40 copayment for each outpatient rehabilitation visit. You havebeen asked to pay $33.10, which is less than the standard $40 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show that the physical therapy visit was provided by telephone conferencing. 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 forphysical therapy provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the full amount forthe core build up (D2950) for teeth # 9 and 13, and the crown (D2740) for tooth # 13.You asked the Plan to pre-approve the full amount forthe dental services. You say that you have never had a crown on tooth # 13. You also say that the crown for tooth # 9 has been covered fully.The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says there is a maximum allowance of $2,500 every year for covered dental services. The Plan also says that the maximum allowance has been reached.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 dentalbenefit in excess of Medicare coverage, core build up is not among those covered under this benefit. Additionally, the $2,500 maximum allowance has been reached. The record shows that the Plan approved $1,210 for the partial denture, $848 for the crown for tooth # 9, and $442 towards the crown for tooth # 13. The Evidence of Coverage clearly states that you are responsible for any amount that exceeds the maximum allowance.Therefore, we decided that the Plan does not have to pre-approve the full amount forthe core build up (D2950) for teeth # 9 and 13, and the crown (D2740) for tooth # 13
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 X2) and implantable neurostimulator electrode, each (L8680 X16).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says your request is not medically necessary because the member's records show the member
does not have one of the covered diagnoses as listed above. The Plan states the member does not have a condition for which this treatment is 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 services. Our physician reviewer found in this case, a request has been made for coverage of a SCS trial for low back pain. The member's low back pain appears to come from significant spinal stenosis. There was no clear evidence of a radicular process on exam. In this case it cannot be determined that the SCS is being prescribed: "To treat intractable pain caused by nerve root injuries, post-surgical or post-traumatic including that of post-laminectomy syndrome (failed back syndrome)." Nor do the medical records provided for review readily support that all other conservative and interventional treatment modalities have been exhausted to date prior to a trial of a SCS. In as much it does not appear that the NCD/LCD requirements for coverage were met. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT Code 63650 X2) and implantable neurostimulator electrode, each (L8680 X16).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe visits you had at a pain management specialist's office from May 15, 2020, to September 2, 2020.You asked the Plan to waive the copayments forthe office visits. You say that you were only seen by a nurse practitioner, not a doctor, so you shouldn't have to pay these copayments.The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment for specialist visits. You have been asked to pay a $40 copayment for the office visits. This copayment applies to all visits in a specialist's office, regardless of whether or not you are treated by a doctor or a nurse practitioner. 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 forthe visits you had at a pain management specialist's office from May 15, 2020, to September 2, 2020.