Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had serious shortness of breath, heaviness in your chest, and dizziness while driving so you pulled over and called your Doctor's office. You were advised to immediately call for an ambulance. You say that the responding paramedics took your vitals, asked you questions and gave you water and oxygen. You say that you were offered transportation to the hospital, however since you were feeling better and thought it would be an expensive visit you declined. You believe that since it was an emergency situation and you were advised to call for the ambulance that the services should be covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance 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-approveIRF care. You say that you need to be monitored to regain mobility.The Plan denied your request. The Plan says this is not medically necessary.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 reasonableand necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status required the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional physical and occupational therapy, but you do not require this therapy or appear to be able to tolerate this therapy on an intensive rehabilitation facility therapy program level in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you will benefit from short-term rehabilitation. The Plan denied your request. The Plan says that your rehab and medical needs can be met at a lower level of care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the therapeutic prophylactic injection provided on September 26, 2019.
You asked the Plan to waive the copayment for the therapeutic prophylactic injection. You say that your plan changed which caused an increase in the injections. You say that you are not able to pay this fee on a fixed income. 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 $20 copayment for services obtained from an in-network specialist. You have been asked to pay $16.11, which is less than the standard $20 copayment for the therapeutic prophylactic injection. The therapeutic prophylactic injection falls 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 copayment for the therapeutic prophylactic injection provided on September 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plandoes not haveto pay foremergency department services provided to the enrollee on August 7, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysit cannot be determined how the enrollee came to the servicing provider, or whether the services are medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Despite multiple attempts, the plan was not able to obtain medical records from the provider. There is very little information about this case that can be used to prove medical necessity. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay foremergency department services provided to the enrollee on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 21, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says that the documentation submitted did not include a valid physician order/lab requisition.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided on August 5, 2019 and August 15, 2019.You asked the Plan to waive the copayments for the ambulance rides. You say that you would like the bills cancelled because your only source of income is Social Security and it is not very high. 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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for each of the ambulance rides. The ambulance rides fall within the "Ambulance Services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the ambulance rides provided on August 5, 2019 and August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora hearing test provided on March 19, 2019 by an out of network (OON) provider.You asked the Plan to pay fora hearing test. You say that this services were medically necessary.The Plan denied your request. The Plan says these services do not meet the urgent/emergent services criteria. The Plan says that no prior authorization was obtained for 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 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 fora hearing test provided on March 19, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 10, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay since there was no medical services provided. The Plan denied your request. The Plan says that you are liable for the copayment.
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 $225 copayment for each Medicare-covered one-way trip in a ground ambulance. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip in a ground ambulance 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 ambulance transport provided on October 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 15, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not want the ride and were forced to take it by the hospital. The Plan denied your request. The Plan says that 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 $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 ambulance transport provided on January 15, 2019.
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 enrollee needs strengthening before returning home.The Plan denied your request. The Plan says this is not medically necessary.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 documentation does not show that the enrollee has any identifiable skilled nursing service needs. While he does have skilled therapy needs, he does not need therapy on a daily basis. He 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-approveskilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridement provided from August 6, 2019 to October 31, 2019.You asked the Plan to waive the copayment forwound debridement. You say that you were not aware that you would owe such high 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 $250 copayment per visit for surgical services provided in an outpatient hospital facility.You received wound debridement from August 6, 2019 to October 31, 2019 for a totalof 3 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $250 copayment per each visit. The total amount you owe is: $750.00. You have been asked to pay the total copayment amount of $750.00 for wound debridement. Wound debridement falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forwound debridement provided from August 6, 2019 to October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 27, 2019.You asked the Plan to waive the copayment for the urgent care visit. You say that there was no service provided. You say that they just sent you to the hospital.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 $50 copayment for each urgent care visit.You have been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show that you were examined and advised to go to the emergency department for further treatment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 27, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from September 13, 2019 through September 20, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan states after a careful review of the denial in  the amount of $4,200.00 for private room charges, it was determined that this charge has already  been reprocessed by  another department and  you are not responsible for this 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). Review of the file shows that you were admitted on September 13, 2019 and discharged on September 20, 2019. You were asked topay a $125 copayment per day from September 13, 2019 through September 19, 2019, days 1-7 of your inpatient hospital care. You were discharged on September 20, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $125 copayment per day required for days 1-7. Your total cost share responsibility is $875 ($125 X 7 days = $875). 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 forinpatient hospital care from September 13, 2019 through September 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 27, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that you were not admitted to the hospital. You say that you are unable to pay it.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 $90 copayment for each emergency room visit.You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the emergency department. 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 forthe ED visit provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 23, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the coding criteria are not supported.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible fora diagnostic colonoscopy provided by provider on September 17, 2019.You asked the Plan to waive the deductible fora diagnostic colonoscopy. You say that you were not aware that you would owe a copayment if polyps were removed and you disagree with the deductible 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. Your contract with the Plan says that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You had polyps removed during a colonoscopy on September 17, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay your share of the cost-sharing charges. The record shows that you had paid $0 toward the $750 deductible. Therefore, you are responsible to pay the allowed amount $207.86. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a diagnostic colonoscopy was received on September 17, 2019.Therefore, we decided that the Plan does not have to waive the deductible fora diagnostic colonoscopy provided by provider on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 23, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you believe it was a routine eye exam. You say that you thought there was no copayment.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 $35 copayment per visit for Medicare-covered specialty care services. You have been asked to pay a $35 copayment for the office visit. The office visit falls 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 copayment forthe office visit provided on September 23, 2019.