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

We decided that the Plan does not have to waive the copayment for urgently needed services provided on March 14, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you already paid the $15 copayment and disagree with the additional 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 $15 copayment for urgently needed services provided by a specialist. You have been asked to pay a $15 copayment for urgently needed services. Urgently needed services fall 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 urgently needed services provided on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert System.
You asked the Plan to pre-approve a Life Alert System. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Telephone Alert Systems will be denied as these are emergency communications systems and do not serve a diagnostic or therapeutic purpose. Therefore, we decided that the Plan does not have to pre-approve a Life Alert System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the enrollee is scheduled for surgery. The Plan denied your request. The Plan says the requested service is available in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chemotherapy drugs.
You asked the Plan to pre-approve the requested drugs. You say that you require chemotherapy for pain control and down-staging of your cancer. The Plan denied your request. The Plan says the costs in a clinical trial are covered by Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the requested drugs as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve chemotherapy drugs.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for specialist services provided on December 16, 2020.
You asked the Plan to waive the coinsurance for specialist services. You say that you feel that the charges are high. 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 15% coinsurance for physician/practitioner services, including doctor's office visits. You received specialist services on December 16, 2020. Therefore, you are responsible to pay your share of the
cost-sharing charges. You are being asked to pay $864.10, which is less than the 15% coinsurance amount. You have been asked to pay $864.10 for specialist services. Specialist services 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 coinsurance for specialist services provided on December 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that transfer to an LTACH is necessary for the enrollee's ongoing and complex medical needs. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at their current inpatient acute care facility, and a transfer to an LTACH is not necessary and does not offer a therapeutic advantage.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is currently receiving acute care services, and these have not been denied. The medical records do not indicate that the enrollee requires services that they are not currently receiving but would be available at the LTACH facility. Coverage rules are not satisfied; the requested transfer cannot be recommended.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myelography via lumbar injection provided on December 22, 2020.
You asked the Plan to waive the copayment for myelography via lumbar injection. You say that you dispute 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 $395 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received myelography via lumbar injection at an outpatient surgical procedure on December 22, 2020.
Myelography via lumbar injection is considered an outpatient surgical procedure. Therefore, you are
responsible to pay the $395 copayment.
You have been asked to pay a $395 copayment for myelography via lumbar injection. Myelography via lumbar
injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities
and ambulatory surgical centers 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
myelography via lumbar injection provided on December 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on July 23, 2020, to July 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the member's facility failed to obtain prior authorization. The Plan says the member's primary care physician did not refer these 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 had network providers available who could have provided 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 skilled nursing services provided on July 23, 2020, to July 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on February 15, 2021.
You asked the Plan to pay for the home visit. You say that it was medically necessary for the patient to be evaluated and the claim should be reprocessed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 home visit provided by an out-of-network provider on February 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (64635, 64636).
You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation. You say that this service is medically necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that the requested procedure is subject to the criteria listed in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve lumbar facet joint radiofrequency ablation. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 78-year-old man who has chronic low back pain. In this case, the patient has other probable pain generators that have not been addressed. In addition, the right sided block should be interpreted as negative and should not be repeated. Finally, the Diagnostic Medial Branch Blocks must achieve greater than 80% pain relief in dual sets of blocks. This was not done for the left side. 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 lumbar facet joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation (64635, 64636).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from October 10,
2020, to October 13, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that the
enrollee should not be responsible for the charges because they were being treated for COVID-19. The Plan
denied your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $215 copayment for days 1-7 for inpatient hospital care.

The medical records show that the enrollee had an inpatient hospital stay from October 10, 2020, to October
13, 2020. Inpatient hospital care is not included in the COVID-19 waiver and is subject to cost-sharing charges.
Therefore, the enrollee is responsible to pay a $215 copayment for days 1-3 (October 10, 2020, to October 12,
2020). However, they are only being asked to pay $430, which is less than the total copayment amount.

The enrollee has been asked to pay $430 for an inpatient hospital stay. An inpatient hospital stay falls within
the inpatient hospital care benefit category. 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 copayment for
an inpatient hospital stay from October 10, 2020, to October 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that your physician noted that the power seat lift is medically necessary and other insurance carriers are funding lift features, therefore, you are expecting the Plan to approve. The Plan denied your request. The Plan says a power seat elevation feature is not covered as they have no medical purpose.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a power seat elevation feature have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided March 10, 2021, by an out of network (OON) provider.
You asked the Plan to pay for the eye exam. You say that neither the enrollee nor the provider was aware the provider was OON since the services were provided at a nursing home facility. The Plan denied your request. The Plan says the criteria for OON coverage are not met.
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 had network providers available who could have provided 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 ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (92004) provided March 10, 2021, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from February 9, 2021, through February 26, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services 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 $345 copayment per day, (per Medicare-covered stay) for days 1-5, which includes the day of admission and the day of discharge for inpatient hospital care. After the 5th day, the Plan pays 100% of the covered expenses.
You have been asked to pay $1,725 ($345 copayment x 5 days) for the inpatient hospital care provided. 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 from February 9, 2021, through February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided
from November 15, 2020, to November 20, 2020.
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that the enrollee
cannot benefit from an inpatient mental health stay and was admitted without his wife present. The Plan denied
your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $275 copayment for days 1-6 for inpatient mental health care.
The medical records show that the enrollee had an inpatient mental health stay from November 15, 2020, to
November 20, 2020. Therefore, the enrollee is responsible to pay a $275 copayment for days 1-5 (November
15, 2020, to November 19, 2020). The total amount the enrollee owes is: $275 (copayment) x 5 (inpatient
mental health days) = $1,375.
The enrollee has been asked to pay the total copayment amount of $1,375 for an inpatient mental health stay.
An inpatient mental health stay falls within the inpatient mental health care benefit category. 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 copayment for an inpatient mental health stay provided from November 15, 2020, to
November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on March 5, 2021.
You asked the Plan to pay for the office visit. You say that you are submitting the medical records for reconsideration of payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 office visit provided by an out-of-network provider on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).

You asked the Plan to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs). You say that you have chronic health conditions since you suffer from high pressure for which have been prescribed Irbesartan, and Metoprolol and your primary care physician (PCP) takes care of your conditions. The Plan denied your request. The Plan says that the certification dated June 2, 2021 documented that you have none of the qualifying diagnoses, you do not require intense care coordination and you have no high risk for hospitalizations or high risk for adverse health outcomes.

The Plan contract says that, in order to be eligible for special supplemental benefits for the chronically ill, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination.

We looked at the file and Medicare rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's benefit. Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill that includes transportation for non-medical needs, an allowance for healthy food purchases and/or electricity, water and/or phone bill payments (debit card), home assistance services (repairs).