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

We decided that the Plan has to pay forthe acute inpatient hospital care provided February 3, 2019 through February 7, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that atthe time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided February 3, 2019 through February 7, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar sacral orthosis provided on January 16, 2020.You asked the Plan to waive the coinsurance for the orthosis. The Plan denied your request. The Plan says that this processed 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% coinsurance for prosthetic devices and related supplies. You have been asked to pay a 20% coinsurance for the orthosis. The orthosis falls within the prosthetic devices and related 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 lumbar sacral orthosis provided on January 16, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on July 31, 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 that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for the laboratory services by the provider. The provider is a contract provider. The
file does not show that the plan provided notice that the laboratory services would not be covered. Under
Medicare rules, this means the laboratory services is considered approved by the plan. Therefore, we decided
that the Plan has to pay for the laboratory services provided on July 31, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe office visit (99213). You say that you would like reconsideration because there is a shortage of Psychiatric prescribers and the member required medication.The Plan denied your request. The Plan says out-of-network Medicare providers 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 forthe medical services provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 9, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon for the Open treatment of femoral
fracture services.
You asked the Plan to pay for the assistant surgeon services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the documentation does not include the credentials of
the assistant surgeon.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the
procedure is covered for an assistant and the person who assists the surgery bears the designation of a
physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP,
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon for the Open
treatment of femoral fracture services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services (71045) provided December 12, 2019.You asked the Plan to pay forthe radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim did not include a valid place of 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 71045 is not supported in the medical record. Specifically, there was not a valid place of service on the claim. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met.Therefore, we decided that the Plan does not have to pay forradiology services (71045) provided December 12, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled nursing visits.
You asked the Plan to pre-approve home health skilled nursing visits. You say that the enrollee's health has
benefited from these services. The Plan denied your request. The Plan says further home health services are not
necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health skilled nursing visits. Our
reviewer says that the criteria for coverage of home health services have not been met. Our physician reviewer
found the enrollee does not require skilled nursing services to safely and effectively provide medically
necessary and reasonable treatment. The patient does not have complex wound care, new enteral feedings, or
other skilled nursing needs. The patient has had extensive prior skilled nursing and should be educated in safely
and management of her conditions which are chronic and stable. Her needs do not require skilled nursing level
care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health skilled nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional home health skilled nursing visits
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90834) provided on January 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary and should be covered. The Plan denied your request. The Plan says the services were out-of-network and were not emergent or preauthorized. There was network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 the outpatient mental health services (90834) provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and predicted period.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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a bone density measurement provided on February 3, 2020.
You asked the Plan to waive the coinsurance for a bone density measurement. You say that you always get the scan done with your yearly mammogram screening with the same provider. 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 50% coinsurance for out-of-network outpatient diagnostic tests and therapeutic services and supplies. You received a bone density measurement on February 3, 2020 from an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network charges. The total allowed amount is $38.61 and 50% of that is $19.30. You have been asked to pay the total coinsurance amount of $19.30 for a bone density measurement. A bone density measurement 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 a bone density measurement provided on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 23, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit after a surgery and you should not be responsible for 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 $35 copayment for specialist services. You had a specialist visit on July 23, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on July 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the cystourethroscopy, the laboratory work, and the office visit provided from January 8, 2020 to January 14, 2020. You asked the Plan to waive the cost share for the cystourethroscopy, the laboratory work, and the office visit. You say that your insurance should pay the entire amount. 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. Your contract with the Plan says that there is a $300 in-network deductible that applies towards in-network outpatient surgery and in-network laboratory services, a 10% coinsurance for each in-network Medicare-covered outpatient hospital facility visit after your yearly deductible is met, a $10 copayment per day, per provider, for in-network Medicare-covered lab services after your yearly deductible is met, and a $10 copayment for each in-network Medicare-covered visit with a PCP. The cystourethroscopy you asked the Plan to waive the cost share for falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This cost sharing is a contractual obligation that had not been met at the time the cystourethroscopy, the laboratory work, and the office visit were received on January 8, 2020 to January 14, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the cystourethroscopy, the laboratory work, and the office visit provided from January 8, 2020 to January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rectum repair provided from September 20, 2019 through September 21, 2019.You asked the Plan to waive the coinsurance for the rectum repair. You submitted your bill for review. You say that you were informed to send it to see if you have to pay the bill.The Plan denied your request. The Plan says the coinsurance 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 Medicare-covered surgery or other services provided to you at an out-of-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $1,729.05, which is 40% of the allowed amount for the rectum repair. The allowed amount is $4,322.63 (40% x $4,322.63 = $1,729.05). The rectum repair falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that the provider is out-of-network. 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 rectum repair provided from September 20, 2019 through September 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 16, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for provider visit. You say that because the enrollee was in a nursing facility, therefore you were not responsible for obtaining authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
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 17, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 1, 2019 to December 12, 2019.
You asked the Plan to pay for the SNF care. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Specifically, the HIPPS codes billed on this claim are invalid as they are not included on the master list of valid/termed codes issued by CMS. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from December 1, 2019 to December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from January 8, 2020 to January 10, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you shouldn't have to pay for this because it you weren't overhydrated you would not have had to go back in to the hospital. The Plan denied your request. The Plan says that the cost sharing 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 $490 copayment for each Medicare-covered day for days 1-4 of inpatient hospital care. You have been asked to pay a $980 copayment for the inpatient hospital services. The inpatient hospital services fall within the Medicare-covered days 1-4 of 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 for the inpatient hospital services provided from January 8, 2020 to January 10, 2020.