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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 30, 2019 through December 2, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 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 shows that you were admitted on November 30, 2019 and discharged on December 2, 2019. You were asked to pay a $250 copayment per day from November 30, 2019 through December 1, 2019, days 1-2of your inpatient hospital care. You were discharged on December 2, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-6. Cost sharing is charged for each inpatient stay. 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 inpatient hospital care from November 30, 2019 through December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve and IRF admission and services.You asked the Plan to pre-approve IRF care.You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says admission to an IRF does not meet criteria. The Plan says that you can safely receive the services needed in other settings such as a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.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 that based on the medical records provided, the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.You do require skilled physical therapy and occupational therapy but based on the medical records provided you do not require treatment in an intensive rehabilitation therapy program.Based on the medical records provided there is concern that you would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case.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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve draw sheets.
You asked the Plan to pre-approve draw sheets. You say that you have quadriplegia. You need this because you experience discomfort in your neck and underarms when your nurse lifts you off the bed without the sheet. It would help both you and your nurse. The Plan denied your request. The Plan says draw sheets/bed sheets are not covered by Medicare. Alternatively, the plan has approved you for a Hoyer lift to facilitate transfers.
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 draw sheets.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on January 16, 2020.You asked the Plan to waive thecopayment forthe office visit. You say that you saw this provider for an acute issue and the issue was not addressed. 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 $15 copayment per visit for a PCP office visit. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were evaluated by the provider.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 office visit provided on January 16, 2020.Your complaint about your unsatisfactory visit is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decisionabout these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 10, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 physician's services provided on December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88108) provided December 16, 2019.
You asked the Plan to pay for the lab services. You say that the services were correctly billed. The Plan denied your request. The Plan says this code cannot be billed with other procedures billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 88108 is not supported in the medical record. Specifically, code 88108 shares a mutually exclusive relationship with code 88112 which was already billed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88108) provided December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
You asked the Plan to pre-approve a CPAP device. You say that the requested item is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that CPAP devices are covered when specific criteria is met. 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 a CPAP device. Our reviewer says that the item is medically necessary. Our physician reviewer found the enrollee's home sleep testing on March 29, 2019 documented a respiratory disturbance index (RDI) greater than 5. There is documentation of insomnia and hypertension. The item is medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have been met. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) device (E0601).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 25,
2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.You asked the Plan to pre-approve the services. You say that the procedure is medically necessary.The Plan denied your request. The Plan says there are in-network provider available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of are a urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp and truck lift.You asked the Plan to pre-approve a wheelchair ramp and truck lift. You say that you need this ramp and truck lift because you are a fall risk and have 3 steps to go down out of your home to your truck.The Plan denied your request. The Plan says these items are convenience items that are for use outside of the home and is therefore 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 wheelchair ramp and truck lift.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on January 9, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you do not feel you should be responsible for the copayment because they only took your blood pressure. 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 each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" category. The record shows you received services during your emergency room visit.This means that you havebeen 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 January 9, 2020.Your complaint that the hospital did not have x-ray equipment to fix the problem is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient visit provided on September 11, 2019.You asked the Plan to waive the copayment forthe outpatient visit. You say that you had to return for a biopsy. You say that you want to know what you are being charged for.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 $150 for each visit to an outpatient hospital facility. You have been asked to pay a $150 copayment for the outpatient visit. The outpatient visit falls within the "Outpatient hospital services" benefit category. The records show that a mammogram, breast biopsy and laboratory services were performed during the outpatient visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient visit provided on September 11, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) and report rendered on
December 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 procedure code 93010 is not supported.
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 93010 is electrocardiogram, routine ECG with at least 12
leads; interpretation and report only.
We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of
an interpretation and report of a routine EKG. 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
electrocardiogram (EKG) and report rendered on December 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on November 4, 2019.You asked the Plan to pay for the problem focused limited oral evaluation. You say that the limited oral evaluation should be a part of the extraction process and should be covered.The Plan denied your request. The Plan says this service exceeds your plan's frequency limitations for oral exams.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, preventive oral examinations are limited to two per calendar year. The record shows that you received periodic oral exams on January 31, 2019 and July 1, 2019 and your preventive oral examinations benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on November 4, 2019.
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 a long term acute care hospital admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The enrollee is receiving necessary services and is at an appropriate level of care. The enrollee may continue care at this level until she is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy and colonoscopy provided on December 19, 2019 and December 27, 2019.
You asked the Plan to waive the copayment for the endoscopy and colonoscopy. You say that you went for a screening test for cancer. You say that there should be no copayment. The Plan denied your request. The Plan says the copayments 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 $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay a total of $582.14 for the endoscopy and colonoscopy.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
December 19, 2019
Endoscopy
$380.05
$350
$350
December 27, 2019
Colonoscopy
$232.14
$350
$232.14
TOTAL:
$582.14
The endoscopy and colonoscopy fall within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy and colonoscopy are considered surgical procedures. 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 and colonoscopy provided on December 19, 2019 and December 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you have diabetes and on the date of service your blood sugar levels dropped. You say that your daughter called 911 and the ambulance responders were dispatched. The paramedics provided you with an insulin shot to help bring your blood sugar back up. You say that you were told by the responders that if your blood sugar had dropped much lower it could have been fatal. You stated that you believe the claim should be covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 5, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (L0650, L1833, and L2397) provided on November 8, 2019.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (L0650, L1833, and L2397) provided on November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the islet cell antibody services provided on September 20, 2019.
You asked the Plan to pay for the islet cell antibody services. 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 supported by the documentation.
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 86341 is islet cell antibody. We find that CPT code 86341 is not supported in the medical record. Specifically, the documentation submitted did not include documentation that islet cell antibody test was completed. Based on this information, we decided that Medicare rules for coverage of the islet cell antibody services have not been met. Therefore, we decided that the Plan does not have to pay for the islet cell antibody services provided on September 20, 2019.