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

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on October 11, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you have to have the procedure done again and disagree with the charges. 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $240.46, which is less than the $300 copayment for arthrocentesis. Arthrocentesis 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 arthrocentesis provided on October 11, 2019.
We note your complaint that you have to have the procedure done a second time. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on October 16, 2019.You asked the Plan to waive the copayment for the endoscopy. You say that you were informed there would be no charge.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurateterms 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 each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center.You have been asked to pay a $150 copayment for the endoscopy. The endoscopy 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 the endoscopy provided on October 16, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physical therapyservices.You asked the Plan to pre-approvethe physical therapy services. You say that you live at a retirement facility and would like to go to the provider that is located closer to you. You say you do not want to travel one and a half hours to goto a network facility. The Plan denied your request. The Plan says the provider is out-of-network.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 will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. The record shows the provider you requested is out-of-network and there are in-network providers available. Therefore, we decided that the Plan does not have to pre-approvephysical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe fecal blood test provided on October 16, 2019.You asked the Plan to waive the copayment forthe fecal blood test. You say that this should have been a part of your annual physical. You say that you were not advised an additional copayment would apply.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must discloseto its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 for Medicare-covered laboratory tests. You have been asked to pay $17.87, which is less than the standard $20 copayment for the fecal blood test. The fecal blood test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate 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 towaive the copayment forthe fecal blood test provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora chemotherapy drug provided by doctor on September 30, 2019.You asked the Plan to waive the coinsurance for a chemotherapy drug. You say that you should only owe a $45 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 20% coinsurance for Medicare Part B prescription drugs. You received a chemotherapy drug onSeptember 30, 2019. The allowed amount is $81.28 and 20% of that is $16.26. You have been asked to pay the total coinsurance amount of $16.26 for a chemotherapy drug. A chemotherapy drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for a chemotherapy drug provided by doctor on September 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a corneal collagen cross link (0402T).You asked the Plan to pre-approve the corneal collagen cross link. You say that you would like reconsideration as this service is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says Medicare considers this procedure not reasonable and necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the corneal collagen cross link have not been met. Specifically, per Local Coverage Article: Billing and Coding: Services That Are Not Reasonable and Necessary (A56967), corneal collagen cross link (0402T) is listed as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve a corneal collagen cross link (0402T).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on September 17, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on September 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve 100 additional routine transports.
You asked the Plan to approve these services. You say that you need transportation to your appointments. The Plan denied your request. The Plan says you have exhausted the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of these services. Therefore, we decided that the Plan does not have to approve 100 additional routine transports.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that the receptionist said that the doctor took your insurance. You say that you cannot afford this copayment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit provided on September 23, 2019 by an out of network(OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on September 5, 2019, September 11, 2019, October 2, 2019 and October 16, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. You say that it is much easier to have the nurse practitioner come to the nursing home than to take your wife out of the nursing home to see in-network providers especially with the complicated care plan. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 domiciliary, rest home visit provided on September 5, 2019, September 11, 2019, October 2, 2019 and October 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on September26, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you went right to the emergency room because you needed to act swiftly. You say you want to appeal the copayment. The Plan denied your request. The Plansays 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 clearlysays that you must pay a $50 copayment for each emergency room visit. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 waive the copayment forthe emergency room visit provided on September 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the forearm surgery provided on October 29, 2018.You asked the Plan to waive the copayment for the forearm surgery. You say that you are elderly and are not in any position to pay such a high amount. 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 $50 copayment for Medicare-covered surgery, other services or each day of observation provided to you at an ambulatory surgical center, including but not limited to other facility charges and physician or surgical charges. You have been asked to pay a $50 copayment for the forearm surgery. The forearm surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the forearm surgery  provided by on October 29, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the PT services provided on August 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the PT services. You say that a new employee handled this case on their own and was not aware of the process. The Plan denied your request. The Plan says utilization of in-network providers is required unless the plan pre-approves out of network services in non-emergent situations.
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 PT services provided on August 20, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran MRI and does not have to waive the coinsurance for a Medicare Part B injection provided by Out of Network (OON) Provider on August 23, 2019.You asked the Plan to waive the copayment for an MRI and to waive the coinsurance for a Medicare Part B injection. You say that you were not aware that you would owe such a high 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 $250 copayment for diagnostic radiology services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.You received an MRI on August 23, 2019. Therefore, you are responsible to pay the $250 copayment. You received a Medicare Part B injection on August 23, 2019. The allowed amount is $40.70 and 20% of that is $8.14. The total amount you owe is: $258.14.You have been asked to pay the total amount of $258.14 for an MRI and a Medicare Part B injection. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B 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 copayment foran MRI and does not have to waive the coinsurance for a Medicare Part B injection provided by Out of Network Provider on August 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of IRF care.
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 member's medical conditions appear stable. There are no wound care needs and there are no unaddressed medical issues. He does not require medical oversight of his condition at an acute hospital level of care. The member requires physical therapy for mobility and endurance. Speech therapy is indicated for treating his dysphagia to decrease the risk of recurrent pneumonia. There is no clear need for occupational therapy. He is ambulating near household distances and does not require an intensive therapy program. The member is limited by debility due to pneumonia. He would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. The member's care can be appropriately provided at an SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from November 10, 2018 to January 4, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says this claim was submitted without a treatment authorization code.The Plan must follow Medicare rules. Medicare rules say that home health claims require a treatment authorization code.The case file did not contain a valid treatment authorization code. 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 for home health services provided to the enrollee from November 10, 2018 to January 4, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the observation stay provided from October 2, 2019 through October 3, 2019.You asked the Plan to waive the coinsurance for the observation stay. You say that you were admitted to observation. You say that the charge is unreasonable.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each outpatient hospital and observation service.You have been asked to pay $550.99, which is 20% of the allowed amount for the observation stay. The allowed amount is $2,754.93 (20% x $2,754.93 = $550.99). The observation stay falls within the "Outpatient hospital 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 coinsurance for the observation stay provided from October 2, 2019 through October 3, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveStelara injection 45mg/0.5 for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested medication is denied as a benefit exclusion.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 Plandoes not haveto pre-approveStelara injection 45mg/0.5 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 10, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 for drug testing services provided to the enrollee on September 10, 2019.