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

We decided that the Plan does not have to reduce the copayments for the MRI and the CT scan provided on November 10, 2020 and November 30, 2020.
You asked the Plan to reduce the copayments for the MRI and the CT scan. You say that you only want to pay a $150 copayment. You say if you had both services done on the same day then you would only have one copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $150 copayment for each Medicare-covered advanced radiology service. You have been asked to pay a $150 copayment for the MRI on November 10, 2020 and a $150 copayment for the CT scan on November 30, 2020. The MRI and the CT scan 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 reduce the copayments for the MRI and the CT scan provided on November 10, 2020 and November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring services provided to the enrollee on June 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services is included in payment to the facility and not separately reimbursable for this provider in this place of service.
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 monitoring services provided to the enrollee on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
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 can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. Your medical conditions are stable and do not require an IRF level of management. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures provided from August 17, 2020, through August 31, 2020.
You asked the Plan to pay for the therapeutic procedures. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 therapeutic procedures. 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 therapeutic procedures provided from August 17, 2020, through August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that this enrollee meets medical necessity for an admission to an IRF. The Plan denied your request. The Plan says the enrollee does not meet the complexity of nursing, medical management, and rehabilitation requiring an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation 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 in the Medicare rules section. 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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. Our physician reviewer also found that the enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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 the acute IRF admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until October 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on August 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic psychiatric evaluation provided on June 3, 2019.
You asked the Plan to pay for the practitioner service. You say that you did not receive proper notice of the enrollee's benefit determination. You say that you should not be penalized for delays in the receipt of information from the facility. You also say that the services were medically necessary. The Plan denied your request. The Plan says the corrected claim was received on October 12, 2020. The Plan also says that this is passed the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the practitioner service was not filed until October 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the diagnostic psychiatric evaluation provided on June 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scan provided on November 3, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you do not understand why you were billed for an out-of-network facility. You say you were told the services would be covered. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment for all other diagnostic and nuclear medicine radiological services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $200 copayment for an in-network CT scan.
You have been asked to pay a $113.40 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the in-network benefit was applied to the CT scan. 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 CT scan provided on November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says it cannot be determined how the enrollee came to the servicing provider.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not contain medical records for the date of service in question. Without records and supporting documentation, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on September 4, 2020.
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 procedure code J1030 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code J1030 is injection, methylprednisolone acetate, 40 mg. We find that CPT code J1030 is not supported in the medical record. Specifically, there is no documentation of an injection of 80 mg methylprednisolone acetate. 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 injection rendered on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the comprehensive oral exam (D0150),
the cleaning (D1110), and the complete series x-ray (D0210).

You asked the Plan to reimburse the full amount for the dental services. You say that you contacted the plan
prior to your visit to verify that the visit would be covered. You say that you were advised that you were
covered for preventive and comprehensive dental up to $1,000 per year. You say that you paid $778 for the
dental services that you and your wife both received. You also say that you only received reimbursement for
$273. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also
says that you may be billed more by an out of network provider if the charge is greater than MAC.

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 and the services are listed as covered,
out of network providers may bill you for any amount greater than the maximum allowable charge. Therefore,
we decided that the Plan does not have to reimburse the full amount for the comprehensive oral exam (D0150),
the cleaning (D1110), and the complete series x-ray (D0210).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 29, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room 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 the emergency room visit provided on December 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you need to go to rehab. The Plan denied your request. The Plan says your request for approval of admission to a SNF does not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the SNF admission have not been met. Although you have skilled therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride.

You asked the Plan to waive the copayment for the ambulance ride. You say that you should not be responsible for the cost share because you could not walk, or drive and the ambulance was recommended by the nurse before going to the emergency department. The Plan denied your request. The Plan says you have been asked to pay 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 $150 copayment per one-way trip.

You have been asked to pay a $150 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 the ambulance ride.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says it
is important to know which providers are part of our network because, with limited exceptions, while you are a
member of our plan you must use network providers to get your medical care and services. The only exceptions
are emergencies, urgently needed services when the network is not available (generally, when you are out of
the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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
diagnostic radiology services. 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 diagnostic radiology services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 additional physical therapy visits.

You asked the Plan to pre-approve additional physical therapy visits. 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 must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have been receiving physical therapy treatments. The documentation does not support that the requested therapy is generally accepted as specific and effective therapy for your condition. Based on the available records, you appear to have plateaued with therapy. Further therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. Therefore, you do 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 additional physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a participating provider on December 3, 2020.
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that this was for your annual screening. 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 as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient diagnostic tests/basic imaging service. You have been asked to pay a $40 copayment for a diagnostic ultrasound. The correct copayment has been applied to the test that was provided. A diagnostic ultrasound falls within the outpatient diagnostic tests/basic imaging service 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 diagnostic ultrasound provided by a participating provider on December 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by on October 26, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 26, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided by a participating specialist on November 12, 2020.
You asked the Plan to waive the copayment for podiatry services. You say that you would like this copayment waived. 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 as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for podiatry services/in-network. You have been asked to pay a $45 copayment for podiatry services. Podiatry services falls within the podiatry services/in-network 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 podiatry services provided by a participating specialist on November 12, 2020.