Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide 2 units of addition to lower extremity prosthesis from an out-of-network provider.
You asked the Plan to provide prosthetic care from an out-of-network provider. You say that you want continuity of care. The Plan denied your request. The Plan says they have in-network providers in your area.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 provide prosthetic care from an out-of-network provider. Our reviewer says that the service from an out-of-network provider is not necessary. Our physician reviewer found the requested out of network continued prosthetic services are not medically necessary per the Social Security Act, Section 1862(a)(1)(A) as the health plan can provide equivalent services for the enrollee. There are no extenuating factors that indicate out of network services for this enrollee's condition are medically necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member over the health plan approved 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 prosthetic care from an out-of-network provider have not been met. Therefore, we decided that the Plan does not have to provide 2 units of addition to lower extremity prosthesis from out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 6, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 physician's 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 physician's services providedon September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 1, 2018.

You asked the Plan to pay for the services provided. You say that the service was provided as self-pay. The Plan denied your request. The Plan says the claim was not received within 12 months from the date the services were rendered.

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 16, 2019. 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 medical services provided to the enrollee on October 1, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on December 20, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve manual wheelchair accessory, wheel lock assembly,
complete, replacement only, each (E2206).
You asked the Plan to pre-approve the item. You say that the durable medical equipment is medically
necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the item have not been met. The E2206 manual wheelchair
accessory, wheel lock assembly, complete, replacement only, each is for replacement only and will not be
covered. Therefore, we decided that the Plan does not have to pre-approve manual wheelchair accessory, wheel
lock assembly, complete, replacement only, each (E2206).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from March 1, 2018 through March 31, 2018, by an out-of-network provider.
You asked the Plan to pay for SNF care. You say that the claim was originally sent within the timely filing limits. The Plan denied your request. The Plan says the claim was not filed timely.
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 SNF care was not filed until November 13, 2019. 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 SNF care provided to the enrollee from March 1, 2018 through March 31, 2018, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 4, 2019 through November 15, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told that it would cost you more if you left the hospital and that you would not pay anything more if you remained there for your rehab. 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 shows that you were admitted on November 4, 2019 and discharged on November 15, 2019. You were asked to pay a $275 copayment per day from November 4, 2019 through November 9, 2019, days 1-6 of your inpatient stay. There were no copayment charges from November 10, 2019, day 7 of your inpatient hospital care until your day of discharge November 15, 2019. Per your contract there is a $275 copayment per day required for days 1-6 for in-network inpatient hospital care. 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 inpatient hospital care from November 4, 2019 through November 15, 2019 provided by an in-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that you have exhausted the 100-day SNF benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from November 15, 2019 through December 9, 2019 and January 6, 2020 through March 21, 2020. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued home health services.You asked the Plan to pre-approvecontinued home health services. You say that you need home health care to recover the strength to do things on your own.The Plan denied your request. The Plan says you do not need skilled services.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 Medicarerules to determine if the Plan was correct in denying the request to pre-approve continued home health services. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found the records do not show a decline in functional or medical status or care plan to warrant skilled rehabilitation or nursing visits. Skilled nursing and rehabilitation visits are not required to effectively provide treatment, care, or services which are 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 continued home health services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued homehealth services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 15, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that the urgent care didn't have the proper staff to treat you. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for an urgent care center visit. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 urgent care visit provided on January 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided outside of the country on June 15, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you were admitted inpatient 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 $120 copayment for emergency care. You had an ER visit outside of the US on June 15, 2019. The record shows that there are no claims for inpatient hospital services on file. Therefore, you are responsible to pay the $120 copayment. You have been asked to pay a $120 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 outside of the country on June 15, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy Tablets 50 mg.
You asked the Plan to pre-approve Ubrelvy. You say that the medication is medically necessary The Plan denied your request. The Plan says the medication is not eligible for coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy Tablets 50 mg
Benefits for Ubrelvy may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) provided to the enrollee on December 13, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the medical records do not support this service.
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 the orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthoses were medically reasonable and necessary for the enrollee in this case. The documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case, as there is no documentation of a physical examination of the wrists, nor a need for wrist orthoses. The medical records do not support the diagnoses of Primary Osteoarthritis of the right and left hands listed on the Physician's Order. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) provided to the enrollee on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on November 15, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. 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 DME provided on November 15, 2019. 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 November 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Care (99225) provided on October 31, 2018. You asked the Plan to pay for the Emergency Room Care. You say that services were medically necessary. The Plan denied your request. The Plan says the claim was filed untimely. 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 Emergency Room Care was not filed until October 1, 2019. 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 Emergency Room Care (99225) provided on October 31, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the post cataract laser surgery (66821) provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for the post cataract laser surgery. You say that you spoke with the provider's office said that a prior authorization had never been a requirement.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 post cataract laser surgery (66821) provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the service is 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 MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical evidence does not support that the MRI was ordered to diagnose disc disease. The provider has already established cervical and lumbar spondylosis. The review has determined that the requested MRI of the lumbar spine is not medically reasonable and 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 an MRI of the lumbar spine have not been met.Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a CT scan, an outpatient hospital stay and
an ER visit provided on November 5, 2019 to November 6, 2019.
You asked the Plan to waive the copayments for a CT scan, an outpatient hospital stay and an ER visit. You say
that you disagree with the charges because the procedure did not work and you had to return to the ER. 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 department visits and a $250 copayment for hospital visits and for CT scans.
You received a CT scan on November 5, 2019. Therefore, you are responsible to pay the allowed amount of
$155.81, which is less than the $250 copayment.
You had an outpatient hospital visit on November 5, 2019. Therefore, you are responsible to pay the $250
copayment.
You had an ER visit on November 6, 2019. Therefore, you are responsible to pay the $90 copayment.
The total amount you owe is: $495.81.
You have been asked to pay the total copayment amount of $495.81 for CT scans for a CT scan, an outpatient
hospital stay and an ER visit. A CT scan, an outpatient hospital stay and an ER visit fall within the outpatient
hospital 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 copayments for a CT scan, an
outpatient hospital stay and an ER visit provided on November 5, 2019 to November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight psychotropic testing provided on December 11, 2019.
You asked the Plan to pay for GeneSight testing. You say that this test is neither experimental nor investigational. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the ordering physician is not a neurologist, psychiatrist, or neuropsychiatrist.
The Plan must follow Medicare rules. Medicare rules say that GeneSight testing is only covered when ordered by a licensed psychiatrist or neuropsychiatrist. We looked at the file and Medicare rules. This testing was not ordered by a psychiatrist or neuropsychiatrist. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight psychotropic testing provided on December 11, 2019.