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

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee would benefit from a LTAC placement.The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.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 there is no evidence that the enrollee requires services that are not currently available. Our reviewer found that as LTACHs and Acute Care Hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. Our physician reviewer also found thatthe enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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-approveLTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe office visit for chemotherapy treatment to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe office visit for chemotherapy treatment. You say that you would like to receive treatment from a tertiary-level provider.The Plan denied your request. The Plan says they have tertiary-level providers in-network able to provide the care you need.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services. In addition, if it is determined that tertiary-level care is necessary, the Plan has approved an in-network tertiary-level provider for you.Therefore, we decided that the Plan does not have to pre-approvethe office visit for chemotherapy treatment to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pontics and retainer crowns provided on December 10, 2019.You asked the Plan to pay forthe pontics and retainer crowns. You say that these services were needed due to an accident you had.The Plan denied your request. The Plan says this claim was processed correctly.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthepontics and retainer crowns provided on December 10, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the vision exam you had on September 21, 2020.You asked the Plan to waivethe copayment. The Plan denied your request. The Plan says you are responsible for the cost share.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 $40 copayment for Medicare covered exams to diagnose and treat diseases and conditions of the eye. Review of the file shows that you had an eye exam on September 21, 2020. You have been asked to pay a $40 copayment for the exam. The exam falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waivethe copayment for the vision exam you had on September 21, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 3, 2020, by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the services rendered by an OON provider.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 had network providers available who could have provided 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 forthe medical services provided on January 3, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) and the office visit (99202) rendered by the out of network (OON) provider from May 24, 2020, through June 11, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 chiropractic manipulative treatment (98941) and the office visit (99202) rendered by the out of network (OON) provider from May 24, 2020, through June 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
on August 3, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you do not have the funds to pay out of
pocket and be reimbursed. The Plan denied your request. The Plan says the drugs that you received are
considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D
prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
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 pay for the self-administered drugs
provided in an outpatient setting on August 3, 2020.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 30, 2020 to August 13, 2020, by an OON provider.You asked the Plan to pay fordomiciliary or rest home visits and advanced care planning. You say that these medically necessary services were provided to the enrollee in good faith and that the provider should not be penalized for the hospital staff's failure to obtain authorization for these services.The Plan denied your request. The Plan says rules for payment have not been met.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 had network providers available who could have provided 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 forthe medical services provided on July 30, 2020 to August 13, 2020, by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on May 28, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says procedure codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services withthe appropriate CPT code.We find that CPT codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical record. Specifically, the file shows that the testing was not performed on blood sampling. Based on this information, we decidedthat Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on May 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinpatient mental health services provided to the enrollee from May 27, 2020 to May 30, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe clinical documentation established that the care was primarily custodial in nature.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, the admission of this enrollee does not meet criteria for acute inpatient mental health treatment as the enrollee was not shown to be a danger to herself or others. There was no auditory or visual hallucinations. She is noted to be cooperative and compliantwith treatment while not showing any aggressive behaviors. The health plan's denial of inpatient psychiatric services appears appropriate.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient mental health services provided to the enrollee from May 27, 2020 to May 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transitional care services provided on October 20, 2020 by an out of network provider.You asked the Plan to pay forthe transitional care services. You say that the services were medically necessary.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 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 had network providers available who could have provided the services at issue in this appeal. 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 forthe transitional care services provided on October 20, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 13, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that all services obtained from out-of-network providers require prior authorization except for emergency or urgently needed services when the network is not available and out-of-area dialysis 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 did not pre-approve the servicesat 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 subsequent nursing facility care provided byon October 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic injection provided on May 24, 2020.
You asked the Plan to waive the copayment for a diagnostic injection. You say that you should only owe a $90 emergency care copayment. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received a diagnostic injection on May 24, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the $350 copayment. You have been asked to pay a $350 copayment for a diagnostic injection. A diagnostic injection 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 copayment for a diagnostic injection provided on May 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient surgery rendered on September 9, 2020.You asked the Plan to waive the copayment forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayment was 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 $250 copayment for Medicare-covered surgery at an outpatient hospital facility. Review of the file shows that you received outpatient surgical services to your foot on September 9, 2020. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered surgery at an outpatient hospital facility 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 outpatient surgery rendered on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing provided on May 5, 2020.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe testing provided on May 5, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from January 4, 2019, to
January 17, 2019 by an OON provider.
You asked the Plan to pay for the medical services. You say that no authorization was requested due to
incorrect information being provided. The Plan denied your request. The Plan says these services were
rendered by a non-network provider who does not work with the enrollee's health plan. The Plan also says that
the enrollee was referred by another non-network provider.
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 had network providers
available who could have provided 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 from January 4,
2019, to January 17, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received from September 14, 2020, to September 30, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not a network provider.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe services you received from September 14, 2020, to September 30, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital inpatient care (99222) provided on July 11, 2019.You asked the Plan to pay forthe hospital inpatient care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says this claim has been filed untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no laterthan one calendar year after the date of service.The record shows that a claim for the hospital inpatient care was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe hospital inpatient care (99222) provided on July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from September 4, 2020, to September 25, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.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 had network providers available who could have provided 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 forthe medical services provided to the enrollee by an out-of-network provider from September 4, 2020, to September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe injection of different drug or substance into a vein for therapy, diagnosis, or prevention (96375, 96367), lipid panel (80061), chemotherapy administration (96413, 96415) and Rituximab injection (J9312) provided on September 18, 2020.You asked the Plan to waive the cost share forthe injection of different drug or substance into a vein for therapy, diagnosis, or prevention, lipid panel, chemotherapy administration, and Rituximab injection. Yousay that you believe you have met your out of pocket maximum.The Plan denied your request. The Plan says the cost share has processed correctly in this case.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 $5 copayment, a 20% coinsurance and a $225 copayment for laboratory tests, Medicare part B chemotherapy drugs and administration,and outpatient hospital services, respectively. You have been asked to pay a total cost share of $387.93 for the injection of different drug or substance into a vein for therapy, diagnosis, or prevention, lipid panel, chemotherapy administration, and Rituximab injection. The services fall within the laboratory tests, Medicare part B chemotherapy drugs and administration, and outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contractwith 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 forthe injection of different drug or substance into a vein for therapy, diagnosis, or prevention (96375, 96367), lipid panel (80061), chemotherapy administration (96413, 96415) and Rituximab injection (J9312) provided on September 18, 2020.