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

We decided that the Plan does not have to waive the copayment for the services provided to the enrollee on
March 15, 2019.
You asked the Plan to waive the copayment for the services. You say that you are appealing the member's costshare
responsibility for the services the member received. The Plan denied your request. The Plan says the
claim was processed accordingly with the member's 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).
The enrollee was admitted to the in-network acute care hospital on March 13, 2019 following treatment in the
emergency department. The Health Plan approved two (2) days inpatient hospital stay from March 13, 2019
through March 14, 2019. The enrollee was discharged from the hospital on March 15, 2019. The enrollee's
EOC clearly states that the enrollee is responsible for $1000.00 deductible before the Health Plan will pay its
share. The enrollee's EOC also states that until the enrollee has paid the deductible amount, they must pay the
full cost for most of their covered services. The Plan processed and paid the claim correctly by applying the innetwork
deductible amount of $159.35 for the inpatient hospital services. 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 the services provided to the enrollee on
March 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from August 16, 2019 through August 31, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you were sent to rehab against your will. You say that the cost isn't fair. 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 $0 copayment per days for days 1-20 and a $172 copayment per day for days 21-100 for each Medicare-covered SNF stays. You have been asked to pay a $1,376 copayment for the SNF stay. ($172/day x 8 days = $1,376). The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The records show that the SNF stay applied SNF days 14-29. 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 SNF stay provided from August 16, 2019 through August 31, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the retrobulbar injection provided on January 29, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that this should not be denied as inclusive to
any other procedures as these procedures are done by different providers and these claims are always paid by
Medicare without the need to appeal. The Plan denied your request. The Plan says that codes for ophthalmic
injections shall not be reported separately with other ophthalmic procedures codes when the injected substance
is an anesthetic.
The Plan must follow Medicare rules. 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.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of 67500 have been met. Specifically, this service was rendered by a provider different than the
provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be
applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes
billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in
support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider
type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor.
Therefore, we decided that the Plan has to pay for the retrobulbar injection provided on January 29, 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 pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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. Our
physician reviewer found the enrollee's medical condition is stable at this time, and he does not have complex
medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician
three times per week.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the member's condition is not complex and does not require supervision by a rehab doctor three times per week.
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. Our physician reviewer found the member does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 5, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the thromboendarterectomy (35301) provided on September 5, 2019.. You say
that you would like reconsideration because you were not given the correct insurance information. The Plan
denied your request. The Plan says the record indicates that the services rendered were not emergent and the
provider did not obtain 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 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 medical services provided on September 5,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the retrobulbar injection provided on January 29, 2020. 
 
You asked the Plan to pay for the retrobulbar injection. You say that this should not be denied as inclusive to any other procedures as these procedures are done by different providers and these claims are always paid by Medicare without the need to appeal. The Plan denied your request. The Plan says that codes for ophthalmic injections shall not be reported separately with other ophthalmic procedures codes when the injected substance is an anesthetic. 
 
The Plan must follow Medicare rules. 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. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of 67500 have been met. Specifically, this service was rendered by a provider different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the retrobulbar injection provided on January 29, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 30,
2019.
You asked the Plan to pay for the hospital outpatient clinic visit. 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
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 a hospital outpatient clinic visit provided on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically
necessary. The Plan denied your request. The Plan says transfer to a LTACH is not medically necessary at this
time. The enrollee is receiving appropriate care at the current acute care facility.
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 pre-approve 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 the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 30 days of continued home health physical therapy (PT).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says that the services are not medically necessary.
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 Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the submitted records show that you have
an unstable, shuffling gait. Your neurologist has requested an extension of home health PT services. The
records support that the services are required to effectively provide treatment, care, and/or services in order to
improve your level of function, or to establish/perform a maintenance program to maintain your level of
function and/or prevent deterioration. The services are reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to preapprove
30 days of continued home health physical therapy (PT).
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: Surgery
Decision: Favorable

We decided that the Plan has to pay for debridement services provided on June 8, 2019 through June 9, 2019.
You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that the qualifying other service/procedure has
not been received/adjudicated.
The Plan must follow Medicare rules. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. the Plan has not made reasonable and diligent efforts to provide medical records
for all dates of service at issue. The service was billed with modifier 78 - indicating treatment for postoperative
complications requiring a return trip to the operating room. This is a separately payable service and
would not be included in the global surgery package. Therefore, we decided that the Plan has to pay for
debridement services provided on June 8, 2019 through June 9, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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. This 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
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 19, 2019.
You asked the Plan to pay for the laboratory 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
service 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 laboratory services provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 11, 2019.
You asked the Plan to pay for these services. You say that you couldn't find a physician that prescribed your
medication. The Plan denied your request. The Plan says the provider has opted out of Medicare.
The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given
by a physician or other practitioner who has opted out of Medicare.
We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit rendered on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheter supplies provided on April 9,
2020.
You asked the Plan to waive the coinsurance for the catheter supplies. You say that you should not be charged
a coinsurance for the catheter supplies and this should be taken care of by the Plan. 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 20%
coinsurance for prosthetic devices and medical supplies.
You have been asked to pay $136.80 which is 20% of the allowed amount for the catheter supplies. The
allowed amount is $684. ($684 x 20% = $136.80). The catheter supplies fall within the "Prosthetic devices and
related supplies" benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the catheter supplies
provided by on April 9, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit provided on
November 12, 2019.
You asked the Plan to waive the copayment for the physical therapy visit. You say that you were charged for an
evaluation that was supposed to include physical therapy. You say the therapist ran out of time and no physical
therapy was performed and you should not be responsible for the copayment. 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 $35
copayment for each specialist visit.
You have been asked to pay a $35 copayment for the physical therapy visit. The physical therapy visit falls
within the "Outpatient rehabilitation services" benefit category. The medical record shows that a low
complexity Physical Therapy Evaluation and treatment were completed at the physical therapy visit.
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 physical therapy visit provided on November 12, 2019.