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

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee does not need any assistance with activities of daily living.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and was treated for anemia. There are no identifiable skilled nursing service needs. Regarding rehab services, she was at a moderate assist level with bed mobility. She required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 3, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you only agreed to pay a $35 office visit copayment not $90. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each Medicare-covered radiological diagnostic service, not including x-rays. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies). You have been asked to pay a $90 copayment for the ultrasound. The ultrasound 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 ultrasound provided on November 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the YAG laser capsulotomy and the Iopidine
drops provided on December 14, 2020.
You asked the Plan to waive the cost share for the YAG laser capsulotomy and the Iopidine drops. You say that
that it did not take long to do the laser surgery on your eye. You say you are having a hard time keeping up
with your bills. The Plan denied your request. The Plan says you have been asked to pay the correct costsharing
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 $225
copayment for each Medicare-covered in-network outpatient hospital facility visit and 20% coinsurance for
each in-network Medicare-covered Part B drug obtained in a provider's office or outpatient setting.
You have been asked to pay a $147.73 copayment, which is less than the standard copayment amount, for YAG
laser capsulotomy. You have been asked to pay $8.88 which is 20% of the allowed amount for the Iopidine
drops. The allowed amount is $44.39. ($44.39 x 20% = $8.88). ($147.73 + $8.88 = $156.61). The YAG laser
capsulotomy falls within the "Outpatient surgery including services provided at hospital outpatient facilities
and ambulatory surgical centers" benefit category. The Iopidine drops 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 YAG laser capsulotomy and the Iopidine drops provided on December 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology provided by a participating provider on January 29, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you do not agree with this copayment. You say that you cannot afford this. 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). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient diagnostic tests/diagnostic radiology. You have been asked to pay a $100 copayment for an ultrasound. The correct copayment has been applied to the services that were provided. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology 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 diagnostic radiology provided by a participating provider on January 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 6, 2020.
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 the services are not authorized, because predictive screening testing is not a benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the obtained laboratory studies are not medically necessary because predictive screening testing is not a Medicare benefit. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services provided on October 15, 2020.
You asked the Plan to pay for the critical care services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billed services are 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 99291 is Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation does not include notes containing the time spent performing the service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Covid testing coded U0004 provided on July 27, 2020.
You asked the Plan to pay for the Covid testing. 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 U0004 is 2019-ncov coronavirus, sars-cov-2/2019-ncov
(Covid-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high
throughput technologies as described by CMS-2020-01-R.
We find that CPT code U0004 is not supported in the medical record. Specifically, the place of service on the
CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage
of the Covid testing have not been met. Therefore, we decided that the Plan does not have to pay for the Covid
testing coded U0004 provided on July 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray images provided on September 23, 2020, by an out-of-
network provider.
You asked the Plan to pay for the x-ray images. You say that you did not know you needed authorization. The
Plan denied your request. The Plan says you did not request prior authorization for the out-of-network service.
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 had network providers
available who could have provided 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 x-ray images provided on September 23, 2020, by an out-of-network
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on January 8, 2021.You asked the Plan to waive the copayment fora CT scan. You say that you 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 $150 copayment for diagnostic radiology services. You have been asked to pay the allowed amount of $141.30, which is less than the $150 copayment for a CT scan. A CT scan 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 fora CT scan provided on January 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on October 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the enrollee could not choose an in-network provider. You say the provider has no prior knowledge of which patient she will be required to see. The Plan denied your request. The Plan says no prior authorization was 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 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 nursing facility care provided on October 1, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Denosumab injection provided on September 28, 2020.
You asked the Plan to waive the coinsurance for the Denosumab injection. You say that you thought your medications would be covered. The Plan denied your request. The Plan says your cost share 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered Part B drug for Medicare Part B prescription drugs. The allowed amount is $971.84, and you are responsible for a 20% coinsurance, resulting in a total coinsurance amount of $182.97. You have been asked to pay a 20% coinsurance for each Medicare-covered Part B drug for the Denosumab injection. The Denosumab 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 coinsurance for the Denosumab injection provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. 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 had network providers available who could have provided 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 physician services provided on July 2, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided on November 1, 2020.
You asked the Plan to pay for incontinence supplies. You say that this is medically necessary. 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 pay for incontinence supplies provided on
November 1, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for routine transportation (A0170).You asked the Plan to pre-approvethe additional mileage. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says your request exceeds the allowable transportation benefit.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.  We looked at your request, the records in the casefile, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Specifically, your request is for an additional 23 miles,a total of 73 milesfor each one-way trip. However, the Plan contract states that coverage is provided for 50 miles of driving distance only for each one-way trip. Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation (A0170)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided from December 4, 2020 to December 5, 2020.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $350 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient surgery from December 4, 2020 to December 5, 2020. You have been asked to pay a $350 copayment for the outpatient surgery. The outpatient surgery falls within the Outpatient surgery 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 outpatient surgery provided from December 4, 2020 to December 5, 2020.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to adjust the copayment. We decided that the Plan does not have to waive the copayment.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan says that the copayment has been applied correctly to the service provided.
We decided that the Plan has to adjust the copayment from $270 to $250. The Plan says you must pay a $270 copayment for the outpatient surgery provided. Based on the Plan contract, however, you cannot be asked to pay more than $250. Therefore, we decided that the Plan has to adjust the copayment for the arthrocentesis, aspiration and/or injection, small joint or bursa (20604) provided on December 4, 2020.
We also decided that the Plan does not have to adjust the copayment. Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery. Therefore, we decided that the Plan does not have to adjust the copayment.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from physician office to residence provided on May 07, 2020.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from physician office to residence provided on May 07, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided December 4, 2020 to December 5, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that please approve the authorization for this enrollee's medically necessary inpatient care. The Plan denied your request. The Plan says this hospital admission was 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 enrollee presented to emergency due to acute severe 7/10 squeezing chest pain and shortness breath. The enrollee indicated intermittent chest pain for 2 weeks prior. The review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
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 December 4, 2020 to December 5,
2020.