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

We decided that the Plan does not have to pay for the medical services provided on November 4, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that it is the responsibility of the doctor to request
authorization. The Plan denied your request. The Plan says you did not request prior authorization for the outof-
network 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 the medical services provided on November 4,
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 to the enrollee on August 27, 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 to the enrollee on August 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from November 18, 2019 to November 19. You asked the Plan to waive the copayment for an ER visit. You say that you cannot afford 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 $0 copayment or $75 copayment for emergency care. Depending on your level of Medicaid eligibility, you may not be responsible for the copayments, coinsurance, or deductibles for the services listed in this section. You had an ER visit from November 18, 2019 to November 19, 2019. The record shows that Medicaid pays your premiums only. Therefore, you are responsible to pay the $75 copayment. You have been asked to pay a $75 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 provided from November 18, 2019 to November 19.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on April 8, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you are unhappy with the service you
received 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 provided on April 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September
10, 2019 through September 11, 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 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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from September 10, 2019 through
September 11, 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 November 6, 2019. You asked the Plan to waive the copayment for the office visit. You say that this was your annual wellness visit. You say that don't know if you discussed a different diagnosis to be considered an office visit. 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 $5 copayment for PCP office visits. You have been asked to pay a $5 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 treated for osteoporosis and hyperglycemia 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 have to waive the copayment for the office visit provided on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on January 19, 2018 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you do not feel liable for the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME on January 19, 2018 provided by an in-network provider. You are asked to pay 20% coinsurance for the in-network DME. 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 DME provided on January 19, 2018 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for an eye exam provided on November 8, 2019. You asked the Plan to waive the deductible and copayment for an eye exam. You say that you already met the deductible 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. Your contract with the Plan says that there is a $225 deductible. Your contract with the Plan also clearly says that after the $225 deductible has been met, enrollees must pay a $30 copayment for vision services. You had an eye exam on November 8, 2019. The record shows that you had only paid $117.87 toward the $225 deductible at the time services were received. Therefore, you are responsible to pay the remaining deductible balance of $107.13. Now that the deductible has been met, you are also responsible to pay the remaining balance of $15.29, which is less than the $30 copayment. The total amount you owe is: $122.42. The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit
category vision care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $225 deductible for vision care. This cost sharing is a contractual obligation that had not been met at the time an eye exam was received on November 8, 2019. Therefore, we decided that the Plan does not have to waive the deductible and copayment for an eye exam provided on November 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve balloon sinus dilation to both maxillary sinuses, both frontal sinuses, and both sphenoid sinuses.
You asked the Plan to pre-approve balloon sinus dilation to both maxillary sinuses, both frontal sinuses, and both sphenoid sinuses. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 balloon sinus dilation to both maxillary sinuses, both frontal sinuses, and both sphenoid sinuses. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has symptoms that are consistent with sinusitis. The CT findings also support the diagnosis of chronic sinusitis. However, they have not been on maximal medical therapy. The standard of care for chronic sinusitis is to proceed with maximal medical therapy prior to proceeding with surgical management. The enrollee was started on intranasal steroids the same month they were advised to undergo a surgical procedure. There is also no documentation that they have tried and failed 2 rounds of culture-directed antibiotics to treat the enrollee's chronic sinusitis. There is no documentation that they have tried sinus rinses. Therefore, proceeding with surgical management of the enrollee's chronic sinusitis is not indicated at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of balloon sinus dilation to both maxillary sinuses, both frontal sinuses, and both sphenoid sinuses have not been met. Therefore, we decided that the Plan does not have to pre-approve balloon sinus dilation to both maxillary sinuses, both frontal sinuses, and both sphenoid sinuses.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 1, 2019 through November 15 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 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 record does show that at the 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. Inpatient admission was medically necessary. 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 for the acute inpatient hospital care provided from November 1, 2019 through November 15 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic colonoscopy, the pathology service, or the Part B injection provided on October 24, 2019. You asked the Plan to waive the cost share for the diagnostic colonoscopy, the pathology service, and the Part B injection. You say that you do not have a copayment for this procedure. You say it should be covered in full by insurance. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $395 copayment per in-network visit, a $5 copayment for in-network Medicare-covered labs, and 20% coinsurance for each in network Medicare-covered Part B drug. The enrollee has been asked to pay total of $395.79 for the diagnostic colonoscopy, the pathology service, and the Part B injection. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The pathology service falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B injection falls within "Medicare Part B prescription drugs" benefit category. The record shows that a biopsy was performed which makes the colonoscopy a surgical procedure in nature. 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 cost share for the diagnostic colonoscopy, the pathology service, or the Part B injection provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148) provided on September 20, 2019. You asked the Plan to pay for the MRI. You say that the MRI was medically necessary. The Plan denied your request. The Plan says there were in-network providers that could provide the services at issue. 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 Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148) provided on September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 7,
2019.
You asked the Plan to waive the copayment for the office visit. You say that you had your annual wellness visit
and discussed all of your health issues and medications. You say you only went to the office one time and there
was not anything different. 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 $5
copayment per primary care physician (PCP) visit.
You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows depression
and constipation were discussed in addition to the annual wellness 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 have to waive the copayment for the office visit provided on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology biochemical assay (4Kscore) testing.
You asked the Plan to pre-approve 4Kscore testing. You say that this test is needed to determine if the enrollee has cancer. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because 4Kscore testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that 4Kscore testing is not considered medically necessary and is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 4Kscore testing have not been met. Therefore, we decided that the Plan does not have to pre-approve oncology biochemical assay (4Kscore) testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on July 2, 2019.
You asked the Plan to waive the copayment for laboratory tests. You say that you received the laboratory tests
as part of a wellness visit and 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 $10
copayment for each laboratory test.
You received laboratory tests on July 2, 2019. Laboratory tests are not included in a wellness visit. Therefore,
you are responsible to pay the $10 copayment.
You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests 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 laboratory tests provided on July 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visits provided on August 25, 2019 and September 1, 2019. You asked the Plan to waive the copayment for the ED visits. You say that you were informed there would be no copayment each time you went back. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the copayments applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for each ED visit. The total amount you owe is $180 ($90/visit x2 visits = $180). The ED visits 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 ED visits provided on August 25, 2019 and September 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on May 25, 2018 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you do not feel liable for the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME on May 25, 2018 provided by an in-network provider. You are asked to pay 20% coinsurance for the in-network DME. 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 DME provided on May 25, 2018 by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from August 25, 2019 through August 27, 2019.You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid.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 Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity.Therefore, we decided that the Plan has to pay for inpatient hospital care provided to the enrollee from August 25, 2019 through August 27, 2019.