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

We decided that the Plan does not have to pay forthe medical services provided on July 31, 2019 to August 7, 2019 by out of network provider, "the provider". You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 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 didnot 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 31, 2019 to August 7, 2019by out of network provider, "the doctor".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive periodontal evaluation provided on June 25, 2019.You asked the Plan to pay forthe comprehensive periodontal evaluation. You say that you got this specific dental office from your insurance company and found out that they are out-of-network during your appointment.The Plan denied your request. The Plan says no benefits are available for procedures performed by out-of-network providers or outside of the providers contracted period. The Plan also says that you contacted them prior to having this service rendered, and you were advised that the providers in this office were no longer contracted under your plan.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe comprehensive periodontal evaluation provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 16, 2019.
You asked the Plan to pay for the office visit. You say that you moved and were not aware it would not be covered by your benefits. The Plan denied your request. The Plan says out-of-network services are not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe sleep study provided on March 11, 2019.You asked the Plan to waive the copayment forthe sleep study. You say that you were told you would not be responsible for a copayment for your second sleep study. 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 $90 copayment for diagnostic procedures and tests at an in-network outpatient hospital. You have been asked to pay a $90 copayment for the sleep study. The sleep study falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived for a second sleep study.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 sleep study provided on March 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee would benefit from LTACH care as he cannot be managed in the SNF setting.The Plan denied your request. The Plan says the enrollee can receive acute hospital care in the current facility indefinitely and there is no reason that he would require transfer to an LTACH.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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include surveillance laboratory studies, intravenous antibiotics, aggressive wound care with debridement, colostomy care, telemetry, nutrition therapy, skin care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 9, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that this was a screening colonoscopy. You say that the point of a screening is to check for polyps.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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed, which makes this a surgical procedure. 
This meansthat 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 colonoscopy provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for pulmonary testing. We decided that the Plan does not have to waive the copayment forpulmonary testing. You asked the Plan to waive the copayment forpulmonary testing. You say that the cost is not correct. You say that you should not owe this amount.The Plan says that the copayment applied correctly.We decided that the Planhas to reduce the copayment forpulmonary testing. 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 withthe Plan clearly says that you must pay a $150 copayment for Medicare-covered non-radiological outpatient diagnostic procedures/tests billed by the hospital. The Plan says that you must pay $225.73 for pulmonary testing. Based on the Plan contract, however, you cannot be asked to pay more than a $150 copayment. Therefore, we decided that the Plan has to reduce the copayment for pulmonary testingfrom $225.73 to $150.  We also decided that the Plandoes not have to waive the copayment forpulmonary testing.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 Medicare-covered non-radiological outpatient diagnostic procedures/tests billed by the hospital. Therefore, we decided that the Plan does not have to waive the copayment forpulmonary testing.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from August 2, 2019to October 21, 2019.You asked the Plan to pay forthe diabetic supplies. You say that  The Plan denied your request. The Plan says that there is no valid proof of delivery.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 itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from August 2, 2019 to October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that the enrollee would benefit from IRF care.The Plandenied your request. The Plansaysthe enrollee is medically stable and does not need three hours of therapy a day.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 was originally admitted 12/13/19 with septic shock and has been hospitalized for a prolonged period. Third spacing was noted on imaging and exams, and initial lactic acid level was >11; creatinine was 2.7. The management has included aggressive diuresis due to fluid overload and congestive heart failure. The enrollee is now slowly stabilizing, and hemodynamics are within acceptable parameters. Records do not indicate that there are significant, or complex medical/nursing issues that require frequent physician management in the hospital setting. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly maximal assist for functional transfers and ADL's and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee's condition has stabilized and she is ready for discharge from the acute care hospital. You say that the enrollee requires LTACH services in order to continue with a multi-disciplinary approach to care, and to return to her previous level of function.The Plan denied your request. The Plan says the guidelines for coverage have not been met. The plan says that the care needed can be provided in the current inpatient hospital.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following a hemorrhagic stroke. The enrollee was intubated and extubated multiple times before eventually receiving a tracheotomy. The enrollee is intermittently tolerating CPAP settings, but with episodes of apnea does not appear to be currently tolerant of ventilator liberation. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time that no acute services are required. The enrolleecan 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BCR/ABL and JAK2 genetic testing.You asked the Plan to pre-approvethese 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. The rules say that BCR/ABL and JAK2 genetic testing are covered for specific indications only.We looked at the file and Medicare rules. The file shows that the testing is being requested for diagnoses of leukocytosis, thrombocytopenia, and squamous cell lung cancer. These are not conditions for which the requested testing are covered by Medicare.Therefore, we decided that the Plan does not have to pre-approveBCR/ABL and JAK2 genetic testing.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for a Laparoscopy and associated services provided on August 6, 2019.You asked the Plan to hold you harmless for the Laparoscopy. You say that you should not be held responsible for the provider's billing error. The Plan denied your request. The Plan says that this is an inpatient only procedure that was rendered in an outpatient setting.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 follows these rules.You were referred for the Laparoscopy by the provider. The provider is a contract provider. The file does not show that the plan provided notice that the Laparoscopy would not be covered. Under Medicare rules, this means the Laparoscopy is considered approved by the plan. Therefore, we decided that the Plan has to hold you harmless for a Laparoscopy and associated services provided on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe custom fabricated abutment on tooth #13 and abutment supported retainers on tooth#'s 10, 11, 13 provided on May 29, 2019.You asked the Plan to pay forthe custom fabricated abutment on tooth #13 and abutment supported retainers on tooth #'s 10, 11, 13. You say that you were told there is coverage on front teeth only and assumed you would receive the full $1,200 benefit since the crowns are on your front teeth.  You also say that customer service told you that crowns on implants are not covered by your contract.The Plan denied your request. The Plan says benefits for a porcelain or ceramic supported fixed partial denture are not covered. The Plan also says that you were informed prior to the services being rendered that these services were not covered benefits under the Plan.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 only covered when they are provided to anterior (front) teeth. Implant services related to tooth #'s 12 and 13 are not covered and neither are the pieces on tooth #'s 10 and 11 that are connected to tooth #'s 12 and 13.Therefore, we decided that the Plandoes not have to pay forthe custom fabricated abutment on tooth #13 and abutment supported retainers on tooth #'s 10, 11, 13 provided on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 15, 2019 by out of network provider.You asked the Plan to pay foroffice visit. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.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 forcare 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 forthe medical services provided on August 15, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 24, 2019 to October 12, 2019.You asked the Plan to pay forthe 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 includethe 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 forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from July 24, 2019 to October 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 20, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that the ambulance costs are not valid. You say that the provider should be responsible.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 $270 copayment for Medicare-covered ambulance benefits. Copayment applies for each one-way trip.You have been asked to pay a $270 copayment for the ambulance transport. The ambulance transport falls 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 copayment forthe ambulance transport provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment coded 98943 provided on September 17, 2019.You asked the Plan to pay forthe extraspinalchiropractic manipulative treatment. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.The Plan must follow Medicare rules. The rules say thatthe only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe extraspinal chiropractic manipulative treatment coded 98943 provided on September 17, 2019