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

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 13, 2020 through March 15, 2020.You asked the Plan to waive the copayment for the inpatient stay. You say that a second operation was done to repair the issue. You say that you shouldn't be responsible for a second copayment.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 $150 copayment per day for days 1-5 per admission for each medically necessary inpatient stay.You have been asked to pay a $300 copayment for the inpatient stay. ($150/day x 2 days = $300). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that this was a separate admission. 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 inpatient stay provided from March 13, 2020 through March 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays provided on January 9, 2020, by a chiropractor.You asked the Plan to pay for the x-rays. You say that the x-rays were necessary before having the adjustment.The Plan denied your request. The Plan says coverage extends only to treatment by means of manual manipulation of the spine to correct subluxation.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Services other than manual manipulation, when performed by a chiropractor, are not covered by Medicare or your plan. Therefore, we decided that the Plan does not have to pay for the x-rays provided on January 9, 2020, by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided to the enrollee on June 28, 2019 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says there is no authorization on file.
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 office visit provided to the enrollee on June 28, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.You asked the Plan to pre-approve a stair glide. You say that you need a stair glide.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 stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any type (E2300), for the enrollee.
You asked the Plan to pre-approve the wheelchair accessory. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you are requesting review of denial of services.
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. The seat elevator system is not justified in the information provided per specialist consultant because it does not show how this system would improve the enrollee's abilities related to their mobility. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any type (E2300), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (S9366) provided February 1, 2020 to February 7, 2020.
You asked the Plan to pay for HCPCS code S9366. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that procedure code S9366 has a status code of I, which is not payable by Medicare.
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 S9366 is not supported in the medical record. Specifically, code S9366 has a status indicator of I and will not be paid by Medicare. This service should be reported with a code that is recognized by Medicare. Based on this information, we decided that Medicare rules for coverage of CPT code S9366 have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9366) provided February 1, 2020 to February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam received on October 19, 2019.
You asked the Plan to pay for the services. You say that you did not call to see if this was in-network since you everybody you know goes to this provider. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover refraction. The service you asked the Plan to pay for is considered an eye exam for the purpose of refraction. Therefore, we decided that the Plan does not have to pay for an eye exam received on October 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided to the enrollee on June 28, 2019 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says there is no authorization on file.
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 office visit provided to the enrollee on June 28, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 2, 2019. You asked the Plan to waive the copayment for the office visit. You say that you reached your maximum out-of-pocket in October. 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 $35 copayment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that your maximum out-of-pocket had not been met prior to the office 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 for the office visit provided on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nasal device and the CPAP provided from January 10, 2020 to February 10, 2020.
You asked the Plan to waive the coinsurance for the nasal device and the CPAP. You say that you should not be responsible for these coinsurance amounts. 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 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. You have been asked to pay $35.69 for the nasal device and the CPAP. The nasal device and the CPAP fall within the "Durable medical equipment (DME) and related supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
January 10, 2020
Nasal device
$93.40
20%
$18.68
February 10, 2020
CPAP
$85.09
20%
$17.01
Total
$35.69
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 nasal device and the CPAP provided from January 10, 2020 to February 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that this is medically necessary. The Plan denied your request. The Plan says further therapy is not needed and the enrollee can continue the exercises he has been shown.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is generally not accepted as specific and effective therapy for the patient's condition. The patient has had extensive prior therapy and should be able to transition to an independent home exercise program. There is no evidence that the patient's high functional level needs further skilled professional physical therapy to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the laryngoscopy you received on December 18, 2019.
You asked the Plan to waive the coinsurance. You say that the services should be covered. The Plan denied your request. The Plan says you are responsible for the cost share.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for out-of-network outpatient surgery. Review of the file shows that you had an out-of-network laryngoscopy on December 18, 2019. The laryngoscopy was allowed at $289.63. You have been asked to pay a 50% coinsurance for the laryngoscopy, totaling $144.82. The laryngoscopy 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 coinsurance for the laryngoscopy you received on December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 22, 2019 through November 24, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 22, 2019 through November 24, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from
November 23, 2019 to November 27, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted as
an inpatient and has never had to pay the emergency room copayment. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment for emergency services at an in-network emergency room.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The record shows you received observation 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 the emergency room visit provided from November 23,
2019 to November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic services by a provider not in your medical group. You asked the Plan to pre-approve the OON services. You say that you are an established patient. The Plan denied your request. The Plan says the requested provider is not in your PCP's specialty network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you may be limited to providers within your Primary Care Provider's (PCP) and/or Medical Group's network. The requested provider in this case is not in your medical group. 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 preapprove these services. Therefore, we decided that the Plan does not have to pre-approve orthopedic services by a provider not in your medical group.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided out of network from January 31, 2020 to February 17, 2020.
You asked the Plan to pay for out of network services. You say that you needed continued care while you were out of network. The Plan denied your request. The Plan says you did not have prior authorization for 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. This was not an urgent or emergent condition. This was ongoing care for a known condition prior to leaving the network. The Plan did not pre-approve out of network chiropractic care. 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 chiropractic services provided out of network from January 31, 2020 to February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the octreotide injection provided on December 24, 2019.You asked the Plan to waive the coinsurance for the octreotide injection. You say that you were treated rudely during the hospital visit. You say that you shouldn't have to pay for the services.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 Medicare-covered Part B drug. Additionally, for the administration of that drug, you will pay the cost-sharing that applies to primary care provider services, specialist services, or outpatient hospital services (as described under "Physician/Practitioner Services, Including Doctor's Office Visits" or "Outpatient Hospital Services" in this benefit chart) depending on where you received drug administration or infusion services. You have been asked to pay $604.10, which is 20% of the allowed amount for the octreotide injection. The allowed amount is $3,020.52 (20% x $3,020.52 = $604.10). The octreotide 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 octreotide injection provided on December 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that these services were referred by a network provider. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that the referring provider is out-of-network. The Plan says that 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 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 lab tests provided on November 24, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.You asked the Plan to pre-approve Euflexxa. You say that the enrollee has tried Synvisc.The Plan denied your request. The Plan says the enrollee has not tried plan-preferred drugs Durolane and Gelsyn-3.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Euflexxa. Our physician reviewer found that a Euflexxa injection of the right knee has been requested for the treatment of osteoarthritis. The documentation indicates that the enrollee had an adverse reaction to Synvisc in the past. The documentation does not support prior trial of Durolane and Gelsyn-3. As such, the Plan's step therapy criteria are not satisfied. It is not shown why the alternatives, Durolane and Gelsyn-3, required by the Plan would not be as effective, or would have adverse effects for the enrollee. Therefore, the requested drug is not considered medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.