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

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 4, 2019 through January 6, 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 review has determined that the record showed 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from January 4, 2019 through January 6, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on October 22, 2019 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you called your provider and ordered a new CPAP mask. You state the nose piece on the mask was too small and the wide option that you received was too large. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 the DME on October 22, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the 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 October 22, 2019 by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided September 11, 2019 through September 12, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this 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 99291 is not supported in the medical record. Specifically, Current Procedural Terminology (CPT) code 99291 25 (1 Unit) remains not supported. This code is included in Current Procedural Terminology (CPT) code 36620 and 93503; therefore, it cannot be separately reimbursed. The documentation submitted does not support a significant, separately identifiable evaluation and management service to support the use of the -25 modifier. In addition, the submitted medical records do not support a critical care visit of 30-74 minutes was performed. Documentation does not include the time spent providing this service. 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 pay for critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided September 11, 2019 through September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 14, 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 the services are not covered.
Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided from October 31, 2019 through November 5, 2019 by an in-network provider.You asked the Plan to waive the coinsurance for the DME. You say that you were told there would be no cost to you to use this provider.The Plan denied your request. The Plan says they reviewed a phone conversation you had with the plan that took place on September 18, 2019 and they heard the representative inform you that there is a 18% coinsurance for DME when obtained from an in-network provider.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 the DME provided from October 31, 2019 through November 5, 2019 by an in-network provider. You are asked to pay 18% 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 from October 31, 2019 through November 5, 2019 by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on November 12, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you were not aware that you would owe a copayment. 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 $50 copayment for each diagnostic radiology and complex imaging service. You have been asked to pay a $50 copayment for a CT scan. A CT scan 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 copayment for a CT scan provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits
You asked the Plan to waive the copayments for specialist visits. You say that the claims should be reprocessed as primary care visits, and this is a financial hardship. 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 $25 copayment for specialist visits. The record shows you had specialist visits on October 17, 2019 and October 31, 2019. Therefore, you are responsible to pay a $25 copayment per each visit. The total amount you owe is: $50. You have been asked to pay the total copayment amount of $50 for specialist visits. Specialist visits fall 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 copayments for specialist visits
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. The Plan denied your request. The Plan says that your routine transportation benefit is exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services provided on September 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forpathology services. You say that you do not see the patient. You say that the specimen is sent to your lab and it is processed. You say that you shouldnot have to get prior authorization when you don't see the patient.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 providerin 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 thePlan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forpathology services provided on September 12, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from 10:01 am on September 19, 2019 to September 20, 2019 at 1:26 pm.
You asked the Plan to pay for these services. You say that the inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 7:13 a.m. on September 19, 2019. The inpatient admission was authorized until 10:00 a.m. on September 19, 2019; all subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 these services. Our reviewer says that the care was post stabilization care not authorized by the health plan. Our physician reviewer found that the review indicates that by 7:13 a.m. on September 19, 2019, the enrollee was stable for transfer to the nearest facility. By this time, the enrollee had a stable repeat head computed tomography scan (CT scan) showing trace to minimal residual subarachnoid hemorrhage, was alert and oriented, hemodynamically stable on Nicardipine weaning protocol, and cleared by the Trauma Team. All lab test results, and diagnostic imaging confirm the enrollee was no longer experiencing an acute neurologic event and no further emergent procedures or testing was ordered. The facility authorized the inpatient admission in the Intensive Care Unit (ICU) until 10:00 a.m. on September 19, 2019. Post stabilization care services after 7:13 a.m. at the non-plan facility were not medically necessary and reasonable. The review has determined the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. 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 inpatient hospital care provided from 10:01 am on September 19, 2019 to September 20, 2019 at 1:26 pm.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and diagnostic testing services provided to the enrollee on June 13, 2019.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.
We find that the CPT codes are not supported in the medical record. In this case, there were insufficient records that clearly document the ordering provider's intent that the test be performed. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and diagnostic testing services provided to the enrollee on June 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of SNF care.
You asked the Plan to pre-approve the SNF care. You say that the member requires therapy and is not ready to
go home. The Plan denied your request. The Plan says the enrollee's care needs at this point are custodial and
can be provided at a lower level.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the member can safely receive care at a
custodial level with intermittent skilled services on a less than daily basis.
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 care have not been met. Therefore, we decided that the Plan does not
have to pre-approve the continuation of SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from February 3, 2019 at 6:05pm through February 5, 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 the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our physician reviewer found the review has determined that the post-stabilization care services February 3, 2019 6:05PM through February 5, 2019 were not medically necessary and reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. 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 hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from February 3, 2019 at 6:05pm through February 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction provided by a non-participating provider on October 15, 2019. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction. You say that your tooth had broken in half and needed to be fixed. You also say that the welcome letter you received from the Plan said nothing about having to go to a specific dentist. The Plan denied your request. The Plan says this provider is a non-participating provider. 
 
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 covered when they are received by a non-participating provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction provided by a non-participating provider on October 15, 2019.  
 
Your complaint about having your premiums refunded is 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport provided on September 27, 2019.
You asked the Plan to pay for the non-emergent ambulance transport. 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.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport provided on September 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 6,
2019.
You asked the Plan to waive the copayment for the CT scan. You say that your doctor said the test should be
covered completely. You say that you can't afford the cost. 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 $125
copayment for CT scans.
You have been asked to pay a $125 copayment for the CT scan. The CT scan 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
copayment for the CT scan provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on November 29, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. There are multiple in network provider within 30 miles of the members residence that could have rendered the 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 outpatient services provided on November 29, 2019 by an out of network (OON) provider.