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

We decided that the Plan does not have to waive the coinsurance for the Retacrit injection provided on February 20, 2020. 
 
You asked the Plan to waive the coinsurance for the Retacrit injection. You say that you thought a doctor's office visit was a $0 copayment. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay $32.40, which is 20% of the allowed amount for the Retacrit injection. The allowed amount is $162 (20% x $162 = $32.40). The Retacrit injection falls within the "Medicare Part B prescription drugs" benefit category. The records show that only the Retacrit injection was billed. 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 Retacrit injection provided on February 20, 2020
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 31, 2019 through September 4, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 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 the review indicates that 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 (ED) and/or observation care) would span two midnights. 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 from August 31, 2019 through September 4, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumbar Epidural Injections (64483).
You asked the Plan to pre-approve the injections. You say that the Lumbar Epidural Injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the injections are covered only when 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 injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found there is no specific clinical rationale for the requested epidural steroid injection in the provided records. The records do not show four weeks of conservative treatment. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Lumbar Epidural Injections (64483).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider from August 2, 2019, to August 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 medical services provided to the enrollee by an out-of-network provider from August 2, 2019, to August 22, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on January 21, 2020.
You asked the Plan to pay for drug test. You say that these tests were ordered by the enrollee's treating physician as medically necessary. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the records do not show why this testing was necessary.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 did not specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for drug testing provided on January 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nuclear medicine test provided on March 10, 2020. 
 
You asked the Plan to waive the coinsurance for the nuclear medicine test. You say that you should not be responsible for the coinsurance because you cannot afford it. 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 outpatient hospital services.  
 
You have been asked to pay $281.78 which is 20% of the allowed amount for the nuclear medicine test. The allowed amount is $1,408.90. ($1,408.90 x 20% = $281.78). The nuclear medicine test 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 coinsurance for the nuclear medicine test provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 21, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you should not owe a copayment because you were not charged for previous follow-up visits. 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 $50 copayment for each specialist visit. You had a specialist visit on February 21, 2020. Specialist visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for a specialist visit. A specialist 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 a specialist visit provided on February 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy provided on October 17, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for massage therapy. You say that you would like these services paid for by the Plan.
The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the
member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 massage therapy provided on October 17, 2019 by
an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ceftolozane 50 mg and tazobactam 25 mg injection provided from January 10, 2019 to January 14, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you were told there would be no cost for these services. The Plan denied your request. The Plan says that the claim 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. The 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 coinsurance for the ceftolozane 50 mg and tazobactam 25 mg injection provided from January 10, 2019 to January 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the walker provided on October 6, 2019 by an out of network provider.
You asked the Plan to reimburse you for the walker. You say that your physician was concerned with the walker you had and ordered you a better walker. The Plan denied your request. The Plan says you did not request prior authorization.
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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to reimburse you for this item. Also, durable medical equipment purchased privately through the internet are not eligible for coverage by your Medicare governed health plan. Therefore, we decided that the Plan does not have to reimburse you for the walker provided on October 6, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post-stabilization services provided from November 24, 2019 to November 27, 2019.
You asked the Plan to pay for the post-stabilization services. You say that the documentation clearly outlines that the enrollee was at risk for an acute adverse event and was appropriate for inpatient admission. You also say that the admission was medically necessary and reasonable. The Plan denied your request. The Plan says the provider did not seek pre-approval from the Plan prior to providing post-stabilization care services.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the post-stabilization services. Our reviewer says that the services did not meet coverage criteria. Our physician reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of care services after the emergency room evaluation on November 24, 2019. There was no documentation provided necessitating post-stabilization care services from November 24, 2019 to November 27, 2019. Our physician reviewer also found that the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 post-stabilization services have not been met. Therefore, we decided that the Plan does not have to pay for the post-stabilization services provided from November 24, 2019 to November 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission. 
 
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 an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the 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 an inpatient skilled nursing facility (SNF) admission.
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 IRF services are medically necessary. The Plan denied your request. The Plan says rules for coverage 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 have a documented need for skilled therapy, including physical and occupational therapy, but there is no documented need for an intensive, complex interdisciplinary rehabilitation course. The enrollee's needs can be met in 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 pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. You say that you are having trouble walking, and are
in constant pain. The Plan denied your request. The Plan says the requested service is not proven for the
treatment of lumbar radiculopathy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 the requested services. Our physician
reviewer found that you present with persistent grade 7 out of 10 low back pain radiating into both lower
extremities. Signs and symptoms are reported consistent with neurogenic claudication. Clinical exam findings
have documented painful and limited range of motion with no focal neurologic deficits. There is imaging
evidence of moderate to severe thecal sac narrowing at L4/5 secondary to broad-based disc bulge. You have
failed long-term conservative treatment, including activity modification, NSAIDs, epidural injection, physical
therapy, and home exercise program. Current evidence based medical guideline and peer reviewed literature do
not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device. The
use of this device has not been studied in patients with active rheumatoid arthritis. The interspinous spacer
device would not be considered safe and effective for treatment of your medical condition. Therefore, this
request is not medically reasonable and necessary.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intravenous infusions provided from
February 1, 2020 to February 7, 2020.
You asked the Plan to waive the copayments for intravenous infusions. You say that you feel that the charges
are way too high. The Plan denied your request. The Plan says the claims were processed correctly and you are
being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received intravenous infusions from February 1, 2020 to February 7, 2020 for a total of 7 visits. Therefore,
you are responsible to pay the allowed amount of $174.52, which is less than the $225 copayment per each
visit. The total amount you owe is: $174.52 (copayment) x 7 (intravenous infusions) = $1,221.64.
You have been asked to pay the total allowed amount of $1,221.64 for intravenous infusions. Intravenous
infusions fall within the outpatient surgery and other medical services provided at hospital outpatient facilities
and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for
intravenous infusions provided from February 1, 2020 to February 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
August 19, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says that the claim 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 $265
copayment for per date of service regardless of the number of ground ambulance trips.
You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls
within the ground ambulance trips 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 August 19, 2019.