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 provided to the enrollee from November 12,2019 through November 21, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee was admitted to the same hospital within five (5) days from discharge of a prior inpatient stay (October 23, 2019 through November 7, 2019).The Plan denied your request. The Plan says the Medical Director did not deem that the second hospital was a continuation of benefits from the previous admission.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 the enrollee was receiving inpatient hospital care from October 23, 2019 through November 7, 2019. The enrollee was then admitted to the same hospital on November 12, 2019 and discharged on November 21, 2019. The Plan's medical reviewer found that these were separate hospitalizations and require separate copayments. The diagnosis for the first inpatient hospital care stay was different than the second inpatient admission. Therefore, the enrollee is asked to pay a $350 copayment for the second inpatient hospital care admission. The enrollee's EOC states, "enrollees must pay a $350 copayment for each Medicare-covered hospital stay. For each Medicare-covered hospital stay, you are required to pay the applicable cost-sharing, starting with Day 1 each time you are admitted. If readmitted within 24 hours for the same diagnosis, the benefit will continue from original admission.You may not owe any additional copayments. In some instances, readmission within 30 days may result in continuation of benefits from the original admission, pending quality medical review by the Plan." This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from November 12, 2019 through November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist office visits provided by an out-of-network specialist on January 2, 2019 to October 31, 2019.You asked the Plan to waive the copayment for specialist office visit. You say that you have been overcharged for 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 $50 copayment for physician/practitioner services/Tier 2 specialist. You have been asked to pay a $50 copayment for specialist office visit. The total amount of office visits that were provider was seven. You were charged less than your $50 copayment for six of these visits. The total amount you are being asked to pay is $270.46 ($25.01 + $25.01 + $50 + $42.61 + $42.61 + $42.61 + $42.61 = $270.46). A specialist office visit falls within the physician/practitioner services/Tier 2 specialist 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 specialist office visits provided an out-of-network provider on January 2, 2019 to October 31, 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 the records provided support the need for transfer to long term acute care for treatment of the enrollee's medical conditions. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH). The enrollee suffered a cardiac arrest and was intubated/ventilated. The enrollee subsequently received a tracheotomy. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on November 15, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you feel that you should not be responsible for the charges due to grievances with the staff. 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 $15 copayment per visit to a primary care provider. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on November 15, 2019.
We note your complaint about the providers staff. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic mammography (77066) and diagnostic digital breast tomosynthesis (G0279) provided on December 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the diagnostic mammography and diagnostic digital breast tomosynthesis provided by an OON provider. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore 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 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 a diagnostic mammography (77066) and diagnostic digital breast tomosynthesis (G0279) provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient readmission from December 14, 2019 to December 19, 2019.
You asked the Plan to pay for inpatient readmission. You say that the services were necessary and payment should be rendered. 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 readmission review involves admissions to an acute, general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or another acute, general, short-term hospital. 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 inpatient readmission. Our reviewer says that the services were medically necessary. Our physician reviewer found while the second hospital stay, starting on December 14, 2019, resulted from a complication of the procedure performed during the first admission, November 25, 2019, it was not reasonable for it to have been diagnosed or prevented. The complication manifested nearly 3 weeks following the procedure. The complication could not have been identified as the enrollee had no symptoms until December 14, 2019. The documentation does not support a premature discharge. The second hospital admission was medically necessary and appropriate for inpatient care on a second hospital stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient readmission have been met. Therefore, we decided that the Plan has to pay for inpatient readmission from December 14, 2019 to December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you are seeking replacement of a raised toilet seat that you have now, that was already a prescribed medical supply that has deteriorated over time. 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 raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate for R. Kingsbury, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 24, 2019.You asked the Plan to pay for the lumbar-sacral orthosis (L0648). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the medical records do not support the claim.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The office visit,before the order date, does not show a face-to-face encounter with information associated with treatment, diagnosing, or managing a clinical condition for the brace.Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0648) have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for percutaneous vertebroplasty and vertebral augmentation procedures (22551) provided July 23, 2019.
You asked the Plan to pay for the percutaneous vertebroplasty. You say that the primary surgeon felt it to be medically necessary for a surgical assistant to be present due to the complexity of the case for a successful and safe outcome. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.
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 22511 is Percutaneous Vertebroplasty and Vertebral Augmentation Procedures. 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 Percutaneous Vertebroplasty Our reviewer says that the records provided do not support billed service. Our physician reviewer found the medical records provided does not include documentation of a percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral being performed on July 23, 2019, therefore, this service cannot be verified. 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 Percutaneous Vertebroplasty have not been met. Therefore, we decided that the Plan does not have to pay for percutaneous vertebroplasty and vertebral augmentation procedures (22551) provided July 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided September 8, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient services were medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 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 September 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on December 23, 2019.You asked the Plan to pay for the periodontal maintenance. You say that you have your teeth cleaned every three months. You also say that you were told that you should be reimbursed up to $150 for the cleanings.The Plan denied your request. The Plan says periodontal maintenance is not included in your dental benefit. The Plan also says that periodontal maintenance is not considered a preventative dental service.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on December 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Outpatient Mental Health services (99214) provided February 6, 2020.
You asked the Plan to waive the copayment for the outpatient mental health services.. You say that the services should have no copay. The Plan denied your request. The Plan says the correct copayment was 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 $25 copayment for Individual or Group therapy visits. You have been asked to pay a $25 copayment for the outpatient mental health services. 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 Outpatient Mental Health services (99214) provided February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on December 27, 2019 by an out of network (OON) provider.
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 the services were rendered without 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 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 genetic testing provided on December 27, 2019 by an out of network (OON) provider.
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 on the date of service you called a nurse line and were told to call 911 in regards to your high blood pressure. The responding ambulance arrived to your house and checked your blood pressure. You say that you were never transported to the hospital and now you have a bill for the ambulance services. You stated that you were just following the nurse's advice and you disagree with the bill. 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 November 28, 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 pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0669).You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four week trial of a basic pneumatic compression device of either E0650 or E0651.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met.Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0669).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 30, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that the provider's office should have contacted your plan to determine if a comprehensive exam would be covered. You also say that you did not know the difference between a periodic exam and a comprehensive exam, and did not know the comprehensive exam would not be covered. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, comprehensive exams are limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation on May 16, 2018 and your comprehensive exam benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on January 30, 2020.