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

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from April 1, 2020 to April 17, 2020.You asked the Plan to waive the copayment for these services. You say that the charges are too much.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment per day for days 1-20 and a $100 copayment per day for days 21-100 for SNF care.Review of the file shows that the enrollee received 16 days of SNF care from April 1, 2020 to April 17, 2020. The enrollee was not assessed a copayment for the date of discharge on April 17, 2020.  The enrollee has been asked to pay a $20 copayment per day for days 1-16 for these services, for a total of $320. These services fall within the SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from April 1, 2020 to April 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 21, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on March 31, 2020.You asked the Plan to waive the coinsurance for the DME. You say that you were told by the provider that the braces are free.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the DME on March 31, 2020. You are asked to pay 20% coinsurance for the DME. Your EOC states, "enrollees must pay 20% coinsurance for Medicare-covered DME and related supplies." 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 forthe DME provided on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent hospital care services (CPT 99232) provided to the enrollee on March 7, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99232 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit."We asked our coding reviewer to carefullyreview 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 supported by the medical records. Our codingreviewer found the documentation received shows that the denied code does not meet criteria for reimbursement, due to the same physician billing same code on the same dates of serviceWe looked at this coder'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 Plan does not have to pay forsubsequent hospital care services (CPT 99232) provided to the enrollee on March 7, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgical services received on January 6, 2020.
You asked the Plan to pay for the services. You say that you want the plan to pay the balance due amounts. The Plan denied your request. The Plan says cost shares are a contractual obligation and cannot be waived.
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 $10 coinsurance for Medicare-covered outpatient surgery. You have been asked to pay $450.80 for the services. The services falls within the Medicare-covered outpatient surgery benefit category. The total is the $96 deductible, plus 10% coinsurance for the surgery, equivalent to $354.80. 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 pay for outpatient surgical services received on January 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids and services purchased on December 19, 2019 from a non-participating provider.
You asked the Plan to pay for the hearing aids and services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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. Review of the file show that the enrollee purchased the hearing aids and services on December 19, 2019 from a non-participating provider. The enrollee's EOC states that the enrollee must see a participating supplemental hearing provider to use the hearing aid benefit. 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 hearing aids and services purchased on December 19, 2019 from a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for health club membership purchased on January 27, 2019.You asked the Plan to reimburse for health club membership. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says they have paid the maximum wellness allowance amount for this benefit.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. You exhausted your maximum benefit allowance. Your EOC states, "the plan reimburses you up to $150 each calendar year towards your cost for membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs such as Matter of Balance, Chronic Disease self-management, diabetes workshop, Healthy Eating for Successful Living,Healthy IDEAS, Powerful Tools for Caregivers, Arthritis Foundation Exercise, Enhance Wellness, Fit For Your Life program, AAA Senior Driving program, memory fitness activities, acupuncture and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician. You pay all charges over $150 per calendar year.Therefore, we decided that the Plan does not have to reimburse for health club membership purchased on January 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided  that  the  Plan  does not  have to pay  for eye refraction  services  (92015) provided  March  10, 2020.You asked the  Plan to pay  for the  vision  services.  You say that this  was a follow  up visit  from  cataract  surgery. You  are requesting  a review  since  this  was the  only  way  the  medical  doctor can proceed with  this  follow  up visit.The Plan  denied  your  request.  The  Plan  says refractive  services  are not covered  unless  rendered  by an in-network  routine  vision  care provider  and completed  as a part of an routine  eye exam.Medicare  generally  does not  cover routine  vision  and eyewear  services.  However,  the  Plan  offers  a routine vision  and eyewear  benefit  that  exceeds  Medicare  coverage.  For that  reason,  the Plan's  coverage  rules  apply  in this  case. The  Plan  covers  these  services  when  provided  by an in-network  routine  vision  care provider.We looked  at the  file  and the  Plan's  rules.  The health  plan  contract  specifically  says  all  eyeglasses  and contact lenses,  including  eye refraction must  be obtained  through  an in-network  vision  provider.  The  refraction  will  not be covered,  even  after  cataract  surgery,  if  performed  or provided  by the specialist,  who is  found  in  the  specialist section  of  the provider/pharmacy  directory.  Based on this  information,  we decided  that  the  Plan's  rules  for coverage  of the  vision  services  have  not been met.Therefore,  we decided  that  the Plan  does not  have to pay for eye refraction  services  (92015) provided  March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your
request. The Plan says step therapy requirement have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that the
criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a
history of osteoporotic fracture or a trial of drug zoledronic acid before they will approve the requested drug.
The documentation does not support a history of an osteoporotic fracture or previous treatment,
contraindication, or intolerance to zoledronic acid.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.
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 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on November 26, 2019.
You asked the Plan to pay for the eyewear. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear 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. You exhausted your $300 maximum benefit allowance. Your EOC states, "if you choose network participating provider, you have the benefit of $300 per calendar year for eyeglasses (prescription lenses, frames, a combination of lenses and frames) and contact lenses, applied at the time of service, and would be responsible to pay for the balance. The supplemental vision plan provider will process the claim. If the cost of the eyewear exceeds the benefit limit ($300 in the supplemental vision plan network, $180 for a non-participating provider), you are responsible for all additional charges." Therefore, we decided that the Plan does not have to pay for the eyewear purchased on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. The Plan denied your request. The Plan says this is not covered
under the enrollee's Part B plan.
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 Trulicity.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a pacemaker check received on January 21, 2020.
You asked the Plan to pay for the services. You say that the charges are too high. The Plan denied your request. The Plan says you are responsible for applicable copayments.
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 an $80 copayment for Medicare-covered diagnostic procedures. You have been asked to pay an $80 copayment for the services. The services fall within the Medicare-covered diagnostic procedures 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 pay for a pacemaker check received on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) provided on February 22, 2020.You asked the Plan to waive the coinsurance for the DME. You say that this machine tore up your legs and you state that you were assured that this was going to be fully covered before you got it.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear,accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) on February 22, 2020. You are asked to pay 20% coinsurance for the DME. Your EOC states, "enrollees must pay 20% coinsurance for DME and related supplies." 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 pneumatic compressor, segmental home model with calibrated gradient pressure (E0652) provided on February 22, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the acute inpatient rehabilitation facility
(IRF) services provided from January 30, 2020 through February 8, 2020.
You asked the Plan to waive the coinsurance for the IRF services. You say that you should not be responsible
for this cost. The Plan denied your request. The Plan says that the cost share was assessed 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%
coinsurance for each Medicare-covered hospital stay for unlimited days received out-of-network.
You have been asked to pay a 30% coinsurance for the IRF services. The IRF services fall within the
Medicare-covered hospital stay for unlimited days received from an out-of-network provider 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 acute inpatient rehabilitation facility (IRF) services
provided from January 30, 2020 through February 8, 2020.
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 requested IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted with a hip fracture after a fall. Her hip fracture was treated surgically. There were no post-operative complications. All chronic medical problems are stable. There are no complex nursing medical or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the
enrollee. You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the enrollee's needs are defined as custodial care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled
nursing or therapy services on a daily basis. 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on March 23, 2020.You asked the Plan to waive the copayment for a specialist office visit. You say that this should be a $0 copayment. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Yourcontract with the Plan clearly says that you must pay a $45 copayment for physician/practitioner services/Basic/specialist visit. You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/Basic/specialist visit 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 office visit provided by a participating provider on March 23, 2020.