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

Medicare rules The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Medicare Managed Care Manual, Chapter 1, Section 20.2.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which the Plan authorizes the use of out-of-network providers. You can find this information in Chapter 3 of the Plan's 2019 Evidence of Coverage.Explanation of decision We decided that the Plan does not have to pay for the physician services provided on November 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for the physician 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 received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.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 physician services provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided.
You asked the Plan to waive the copayment for the EKG. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you had an EKG during your visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for Medicare-covered non-radiological diagnostic services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received an EKG during your physician visit. You have been asked to pay an $18.78 copayment for the EKG, which is less than the contracted $20 copayment amount. The EKG falls within the Outpatient diagnostic tests 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 EKG provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.You asked the Plan to pre-approve a semi-electric hospital bed (E0260). You say that because of medical issues you have to sleep with your head at an angle.The Plan denied your request. The Plan says you do not meet criteria.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 a semi-electric hospital bed (E0260). Our reviewer says that the semi-electric hospital bed is not medically necessary. Our physician reviewer found the documentation does not reveal that the enrollee is unable to reposition herself in a regular bed. The documentation states that despite propping up with pillows or sleeping in a recliner the reflux is worse. The enrollee does not need special attachments that cannot be fixed on an ordinary bed. The documentation states the enrollee needs frequent repositioning due to back pain but does not describe the severity and frequency of the symptoms of the condition that necessitates a hospital bed for positioning. It is not clear why the enrollee is unable to reposition in a regular bed. The enrollee does not require immediate body repositioning. The criteria for a semi electric bed E0260 has not been met per the  Medicare National Coverage Determinations Manual, Section 280.7(A). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed (E0260) have not been met.Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair power seating tilt and center mount power elevating leg platform.You asked the Plan to pre-approve power wheelchair power seating tilt (E1002) and center mount power elevating leg platform (E1012). You say that the enrollee needs these options. The Plan denied your request. The Plan says the consulting evaluation does not show a need for power tilt and power articulation foot platform.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 power wheelchair power seating tilt (E1002) and center mount power elevating leg platform (E1012). Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the power wheelchair power seating tilt and center mount power elevating leg platform are not medically necessary. Per medical records the enrollee is able to transfer with stand and pivot for now and recommended to start a sliding board for transfers. A September30, 2019 PMD evaluation indicates the enrollee's upper extremity strength is 4/5 on right and 4-/5 on left with full range of motion which should be adequate to weight shift. The enrollee should be able to elevate the legs,  is able to weight shift, transfer, and can transfer to elevate legs if indicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair power seating tilt (E1002) and center mount power elevating leg platform (E1012) have not been met.Therefore, we decided that the Plan does not have to pre-approve power wheelchair power seating tilt and center mount power elevating leg platform
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided
March 30, 2019 to April 5, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the copayment was applied correctly to the inpatient hospital care provided.
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 $290 copayment per day, for days 1-7 for inpatient hospital care. You have been asked to pay a $1,740 copayment ($290 per day x 6 days) for 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 the inpatient hospital care provided March 30, 2019 to
April 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for ostomy supplies provided on November 15, 2019 by an out-of-network provider.You asked the Plan to waive the deductible for the ostomy supplies. You say that you reorder the ostomy supplies every three months and that the Health Plan has paid your previous claims but denied the ostomy supplies on November 15, 2019.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 ostomy supplies provided on November 15, 2019 by an out-of-network provider. At the time of services rendered you had not met your $1,000 deductible; therefore, you have been asked to pay $265 for the services to apply to your deductible. Your EOC states, after you pay your $1,000 deductible, you pay: 20% coinsurance for out-of-network medical supplies. 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 deductible for ostomy supplies provided on November 15, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from October 23, 2019, 2019 through October 24, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says 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 Medicarerules. 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 forthe acute inpatient hospital care provided from October 23, 2019, 2019 through October 24, 2019
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99222) provided.
You asked the Plan to pay for hospital care. You say that this service was not related to hospice. The Plan denied your request. The Plan says payment for this service is the responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital care (99222) provided.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met.Therefore, we decided that the Plan does not have topre-approveskilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care 
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 indicates 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 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says members are required to obtain all covered services from network providers when in area and must have prior authorization when not an emergency. These services were not urgent or emergent and were available if the member had requested.
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 provided.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 13, 2019 through November 16, 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 indicates 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 November 13, 2019 through November 16, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from November 26, 2019 through December 6, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you believe that if a person is readmitted to a hospital within 30 days of being discharged from a previous stay, the copayment does not apply.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 inpatient hospital care from November 26, 2019 through December 6, 2019. You are asked to pay a $345 copayment for days 1-5 of your inpatient hospitalcare. Your cost share starts the day you are admitted as an inpatient in a hospital or skilled nursing facility. You pay no cost share for the day you are discharged. 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 Plandoes not have to waive the copayment forinpatient hospital care from November 26, 2019 through December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reimburse for inpatient hospital care from August 13, 2019 through August 16, 2019 provided by an out-of-area provider.You asked the Plan to reimburse for inpatient hospital care. You say that you are requesting reimbursement of services rendered.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 received inpatient hospital room and board from August 13, 2019 to August 16, 2019. You are responsible for the copayment for three days of inpatient hospital care. If the plan applied a $250.00 copayment to three days of inpatient care, the total copayment due would be $750.00 ($250.00 x 3). However, you were only billed the amount of $531.00 for the inpatient hospital care by the out-of-area provider. The conversion rate for 73,096 Jamaican dollars totals $536.09.  The amount billed by the out-of-network provider is less than what the $750.00 copayment would be. Therefore, you are not due any reimbursement for the inpatient hospital charge. 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 reimburse for inpatient hospital care from August 13, 2019 through August 16, 2019 provided by an out-of-area provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral evaluation -problem focused (D0140) and intraoral -periapical first radiographic image (D0220) provided on January 14, 2020.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.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 among those covered under this benefit. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forlimited oral evaluation -problem focused (D0140) and intraoral -periapical first radiographic image (D0220) provided on January 14, 2020.