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

We decided that the Plan has to pay for and apply the inpatient-level of care cost share amount for the acute inpatient hospital care provided on June 8, 2019 through June 11, 2019.
You asked the Plan to pay for and apply the inpatient-level of care cost share amount for acute inpatient hospital care. You say that these services were urgent and medically necessary. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for and apply the inpatient-level of care cost share acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, the Evidence of Coverage 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 and apply the inpatient-level of care cost share amount for the acute inpatient hospital care provided on June 8, 2019 through June 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased at a non-contracted provider on August 23, 2019.
You asked the Plan to pay for the hearing aids. You say that you were advised by customer service that you could obtain hearing aids. The Plan denied your request. The Plan says you do not have out-of-network benefits.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. The provider is not in-network and your EOC clearly states, the hearing care services must be authorized and performed by a Participating Referral Physician or Participating Audiologist. The Hearing Aid must be dispensed by a Participating Provider (Hearing Aid Dealer or specialist). Therefore, we decided that the Plan does not have to pay for the hearing aids purchased at a non-contracted provider on August 23, 2019.
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 will have better recovery at a rehab facility. You say that you are unable to go home and take care of yourself. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the BRCA genetic testing rendered to the enrollee on June 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered for patients suspected of hereditary breast and/or ovarian cancer syndromes. We looked at the file and Medicare rules. The file shows that the enrollee did not have a personal history of cancer or signs/symptoms of cancer. Therefore, we decided that the Plan does not have to pay for the BRCA genetic testing rendered to the enrollee on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemodenervation and Botox injection provided on August 20, 2019.
You asked the Plan to waive the cost share for the chemodenervation and Botox injection. You say that you were approved for Botox injections. You say that you were informed you would only have a $30 copayment. The Plan denied your request. The Plan says the cost share 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 $30 copayment for each Medicare-covered specialist visit. Covered services include Medically-necessary medical care or surgery services furnished in a physician's office. Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare&#8209;covered Part B Chemotherapy drugs and other Part B drugs.
You have been asked to pay a total of $274.96 for the chemodenervation and Botox injection.
Date of Service
Service
Allowed Amount
Standard Cost Share
Member Liability
August 20, 2019
Chemodenervation
$1,224.80
20%
$244.96
August 20, 2019
Botox Injection
$141.12
$30
$30
TOTAL:
$274.96
The chemodenervation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Botox injection falls within the "Medicare Part B prescription drugs" 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 cost share for the chemodenervation and Botox injection provided on August 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided on October 9, 2019.
You asked the Plan to waive the copayment for an observation stay. You say that you were told that you would
not be billed for observation. 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 $300
copayment for an observation stay.
The medical records show that you had an observation stay on October 9, 2019. Therefore, you are responsible
to pay the $300 copayment.
You have been asked to pay a $300 copayment for an observation stay. An observation stay 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 for an
observation stay provided on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from August 19, 2019 to November 7, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of
Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose
monitor, test strips, lancets, control solution, and lancet device provided from
August 19, 2019 to November 7, 2019.
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 documentation provided supports the need for IRF care. The Plan denied your request. The Plan says the criteria for coverage of IRF care have 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. The enrollee is requiring some assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable and predictable period. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis, and suspension sleeve provided on July 26, 2019.
You asked the Plan to pay for the knee orthosis (L1851), and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis, and suspension sleeve provided on July 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 12, 2019 to October 31, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 12, 2019 to October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 9, 2019 to October 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgical procedure on January 22, 2019.
You asked the Plan to waive the coinsurance for an outpatient surgical procedure. You say that you should not be responsible for any 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 20% coinsurance for each outpatient hospital facility visit. You had an outpatient surgical procedure on January 22, 2019. The allowed amount is $8,796.95 and 20% of that is $1,759.39. You have been asked to pay the total coinsurance amount of $1,759.39 for an outpatient surgical procedure. An outpatient surgical procedure falls within the outpatient surgery, including 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 coinsurance on January 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an ultrasound (93306), a nuclear stress test (78452), and a regadenoson injection (J2785) provided on July 16, 2019.
You asked the Plan to waive the cost-sharing for an ultrasound, a nuclear stress test, and a regadenoson injection. You say that you cannot afford these charges. The Plan denied your request. The Plan says these services processed 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 $90 copayment for each covered diagnostic procedure or test at a network doctor's office, pay a $105 dollar copayment for covered diagnostic radiology services in a provider's office or freestanding radiology center, and a 20% coinsurance for drugs covered by Medicare Part B. You have been asked to pay a $90 copayment for an ultrasound, which is a diagnostic procedure you received at a network doctor's office; a $105 copayment nuclear stress test, which is a diagnostic radiology service; and $46.18 for a regadenoson injection, which is a drug covered by Medicare Part B (20% coinsurance x the $230.92 allowed amount = $46.18). 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 cost-sharing for an ultrasound (93306), a nuclear stress test (78452), and a regadenoson injection (J2785) provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 8, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that 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 $25 copayment for provider and professional services at an in-network specialist's office visit. You have been asked to pay a $25 copayment for the specialist office visit. The specialist 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 for the specialist office visit provided on October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan eye drops for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan eye drops for the
enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 15, 2019
You asked the Plan to waive the copayment for the MRI. You say that you were not aware you would have a high copayment for this service. You say that you thought you would pay your normal x-ray 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 $150 copayment for each Medicare-covered advanced radiology service. You have been asked to pay a $150 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the MRI provided on October 15, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 16, 2019.