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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not have a need for intensive rehab, complex medical conditions which require physician supervision, or a multidisciplinary team for care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our physician reviewer found that you are generally medically stable after a hip fracture and surgery, with no recent neurological or acute complicating events. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. Currently you are at minimal assist for mobility and activities of daily living. While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the tissue exam provided on January 28, 2020.
You asked the Plan to waive the copayment for the tissue exam. You say that you had no say as to where the provider sent the specimen. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for laboratory services at an out-of-network specialist's office. You have been asked to pay a $65 copayment for the tissue exam. The tissue exam falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows your dermatologist is an out-of-network provider.
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 tissue exam provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an eye exam provided on February
21, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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
services at issue. 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 for an eye exam provided on February 21,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second lumbar epidural steroid injection (62323).
You asked the Plan to pre-approve a second lumbar epidural steroid injection. You say that the enrollee needs 2 LESIs. The Plan denied your request. The Plan says they will approve one LESI and review for medical necessity of a future injection.
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 second lumbar epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a second lumbar epidural steroid injection.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient behavioral health services (99397, 96127) provided on March 6, 2020.
You asked the Plan to pay for the outpatient behavioral health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized and are non-covered.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the outpatient behavioral health services (99397, 96127) provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the cost for the anesthesia provided on January 2, 2020.
You asked the Plan to reduce the cost for the anesthesia. You say that all physician services provided at an in-network hospital are covered. You say that the anesthesia services should be considered in-network. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that physician services are excluded from the Plan deductible. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan says you must pay $1,000 for physician services. Based on the Plan contract, however, you cannot be asked to pay any deductible amount for physician services because physician services are excluded from the Plan deductible.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The records do not show whether the servicing hospital facility is in-network or out-of-network with the Plan. Without this information, we cannot determine whether this inpatient physician service would be included in the per day copayment applied to in-network inpatient stays. Therefore, the Plan has not shown that its decision to apply separate cost-sharing to this claim is correct or justified according to Medicare rules and the Plan contract. Therefore, we decided that the Plan has to waive the $201.97 toward the deductible for the anesthesia provided on January 2, 2020.
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 for an inpatient mental health stay provided from October 6, 2019 to October 17, 2019.
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you disagree with the charges because you are unhappy with the facility. 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 $295 copayment per day for days 1-5 for inpatient mental health care. You received an inpatient mental health stay from October 6, 2019 to October 17, 2019. Therefore, you are responsible to pay a $295 copayment for days 1-5 (October 6, 2019 to October 10, 2019). $295 (copayment) x 5 (inpatient days) = $1,475. You have been asked to pay the total copayment amount of $1,475 for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient mental health 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 inpatient mental health stay provided from October 6, 2019 to October 17, 2019.
We note your complaint that you are unhappy with the facility. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture (D5212) provided on February 5, 2020.You asked the Plan to pay for the lower partial denture. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the lower partial denture is not a covered benefit under your contractual policy.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 item provided is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe lower partial denture (D5212) provided on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin biopsy provided on February 27, 2020.
You asked the Plan to waive the copayment for the skin biopsy. You say that you don't know why you are being charged for an observation room. You say that you paid a $40 copayment at the time of service. 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 $350 copayment for each Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay $215.04, which is less than the standard $350 copayment for the skin biopsy. The skin biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The skin biopsy is considered a surgical procedure that was billed by the hospital. 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 skin biopsy provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 5, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 13, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that 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 services at issue. 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 on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that you need a Group 3 power wheelchair, accessories, and upgraded electronics. The Plan denied your request. The Plan says your upper limb strength and function are adequate for you to be able to control the power options using their own switches.
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. The documentation indicates that you have sufficient functional ability in the upper extremities to control the power features through their own individual switches. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 18, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you pay $89 a year for this service. You say that you thought that covered your service. 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 ambulance transport provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee provided on May 7, 2018.
You asked the Plan to waive the copayment for the facility fee. You say that you were not admitted to the hospital. You say you would like the claim reprocessed and paid as an office visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $325 copayment for the facility fee. The facility fee falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
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 facility fee provided on May 7, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee on August 18, 2018. You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that that they will not pay for these services. 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. 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 and/or observation care) would span two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for acute inpatient hospital care. 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 to the enrollee on August 18, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve localization of tumor imaging (3D) for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary due to a family history of essential tremor. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the imaging. Our reviewer says that the requested imaging is not medically reasonable or necessary. Our physician reviewer found in this case the SPECT scan has been ordered for an indication/condition for which it is not supported for use within the applicable Medicare NCD. The enrollee has been followed by neurology for an initial presentation of a tremor. Her symptoms have since progressed and she is now suspected of potentially having Parkinson's Disease. The diagnosis of Parkinson's Disease has historically been made on the basis of clinical examination and findings. Current literature otherwise shows that the overall accuracy of DaTscan for parkinsonian syndromes is equal to but not better than the accuracy of a carefully obtained clinical diagnosis. There are also limitations with the specificity of this type of imaging study as well. In as much it cannot be determined that this service would otherwise be reasonable and necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve localization of tumor imaging (3D) for the enrollee.