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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 10, 2019 through September 13, 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 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical record stated that the enrollee was medically stable for transfer to rehabilitation facility and the enrollee's status was documented as custodial. Inpatient admission care from September 10, 2019 through September 13, 2019 was not medically 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 10, 2019 through September 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services you received from December 29, 2019, to January 2, 2020.
You asked the Plan to waive the cost share. 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 $35 copayment for each specialist visit. Your contract with the Plan also says that you must pay a $90 copayment for emergency care. Your contract with the Plan also says that you must pay a 20% coinsurance for Medicare Part B drugs. Review of the file shows that you had two office visits, emergency care, and were provided Part B drugs, from December 29, 2019, to January 2, 2020. You have been asked to pay a $35 copayment for each visit, a $90 copayment for the emergency care, and a 20% coinsurance for the Part B drugs. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the services you received from December 29, 2019, to January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee was previously receiving them and you do not understand why this is not a covered benefit now. These needs to be approved due to incontinence. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on February 19, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you were told that the insurance would
take care of the service. You say you would not have had the service done if you had known there was a $100
copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing
amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100
copayment for Medicare-covered outpatient x-rays for services provided by an in-network specialist at an
outpatient hospital.
You have been asked to pay a $100 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the x-ray provided on February 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on February 13,
2020
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 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 a hospital outpatient clinic visit provided on February 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on April 2,
2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you sent your bill in for
review. 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 $240
copayment for each in-network Medicare-covered one-way trip via ground ambulance.
You have been asked to pay a $240 copayment for the ambulance ride. The ambulance ride falls within the
"Ambulance services" benefit category. The medical record shows you received the ambulance service.
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 ride provided on April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert System (A9280).You asked the Plan to pre-approve a Life Alert System. You say that you do not understand why an alert device has been denied after you have been told several times that this is covered under your plan with no copay.The Plan denied your request. The Plan says this is a convenience item and is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a Life Alert System (A9280).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 14, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug panels provided on
October 7, 2019.
You asked the Plan to pay for the drug testing panels. You say that this medically necessary testing should be
paid. The Plan denied your request. The Plan says there is no evidence that the enrollee has been seen by the
provider ordering this test. As such, this is not covered.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a
treating practitioner who has furnished a consultation with the enrollee.
In this case, there is no record showing that the enrollee was seen by the ordering physician and the Plan has
attested that there is no claims history documentation showing an established relationship. Without medical
records to show that this enrollee was seen prior to this test being ordered, the rules for coverage of the drug
testing panels have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive
and definitive drug panels provided on October 7, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the retrobulbar injection provided on January 13, 2020.
You asked the Plan to pay for the retrobulbar injection. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that codes for ophthalmic injections shall not be reported separately with other ophthalmic procedures codes when the injected substance is an anesthetic.
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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, this service was rendered by a provider different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the retrobulbar injection provided on January 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravitreal injection of a pharmacologic agent or waive the coinsurance for the Lucentis provided on February 28, 2020.
You asked the Plan to waive the copayment for the intravitreal injection of a pharmacologic agent and waive the coinsurance for the Lucentis. You say that you cannot afford to pay for this. 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 $35 copayment for each specialist visit for Medicare-covered services and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $35 copayment for the intravitreal injection of a pharmacologic agent and a 20% coinsurance for the Lucentis. The intravitreal injection of a pharmacologic agent falls within the specialist visit for Medicare-covered services benefit category and the Lucentis falls in 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 copayment for the intravitreal injection of a pharmacologic agent or waive the coinsurance for the Lucentis provided on February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care provided to the enrollee August 19, 2019 through August 22, 2019 provided by an out-of-network provider.
You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 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 the enrollee received inpatient hospital care from August 19, 2019 through August 22, 2019 provided by an out-of-network provider. The enrollee is asked to pay 40% coinsurance for the out-of-network inpatient hospital care. The enrollee's contract states, "after you pay your $750 deductible, you pay 40% per stay for out-of-network medically necessary covered inpatient stay." 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 coinsurance for inpatient hospital care provided to the enrollee August 19, 2019 through August 22, 2019 provided by an out-of-network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (G0470, 90834)
provided on January 6, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically
necessary. The Plan denied your request. The Plan says coverage criteria has 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 has network providers
available who can provide 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 for the outpatient mental health services (G0470, 90834) provided on January 6,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 3, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the laboratory services. 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 laboratory services provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have had lumbar surgery and are at risk of falling in your home. You say that you need the requested shower chair because the risk of falling could cause you injury. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a TENS unit.
You asked the Plan to pre-approve the unit. You say that this is medically necessary. The Plan denied your
request. The Plan says the medical records do not indicate enrollment in a clinical study.
The Plan must follow Medicare rules. Medicare rules say that a TENS is covered when the beneficiary is
enrolled in an approved clinical study.
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 unit. Our reviewer says that the
requested unit is not considered medically reasonable and necessary in this case. Our physician reviewer found
the enrollee is not an approved clinical trial of TENS. There is no approved diagnosis for a TENS unit. The
request is therefore deemed not medically reasonable or 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 unit have not been met. Therefore, we decided that the Plan does not have to
pre-approve a TENS unit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ophthalmic imaging and ranibizumab injection provided on March 27, 2020.
You asked the Plan to waive the cost share for the ophthalmic imaging and ranibizumab injection. You say that you are unemployed and cannot afford this. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each Medicare-covered diagnostic procedure and test in an in-network specialist's office and 20% of the plan-allowed amount for Medicare Part B covered drugs from an in-network provider. You have been asked to pay a total of $465.57 for the ophthalmic imaging and ranibizumab injection.

The ophthalmic imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ranibizumab injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the ophthalmic imaging and ranibizumab injection provided on March 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. The Plan denied your request. The Plan says that 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 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 medical services provided on February 11, 2020 by an out of network (OON) provider.