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

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.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 rulesto 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 you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is not at his baseline.The Plan denied your request. The Plan says the enrollee's rehab needs are not complex, and he does not need a rehab doctor at least 3 times a week.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 physician reviewer found that the enrollee was admitted to the acute hospital for weakness and repeated falls. He was treated for urinary infection, pneumonia and had a PEG tube placed for continuous tube feeding. His medical conditions are stable. The complexity of hisnursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabprogram.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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital services received
from December 20, 2018, to December 24, 2018, from an out-of-network (OON) provider.
You asked the Plan to waive the coinsurance for the inpatient hospital services. You say that you believe you
had already reached your out-of-pocket maximum prior to the date of service. The Plan denied your request.
The Plan says the coinsurance has applied correctly, and no reimbursement is due.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a 50% coinsurance for OON inpatient hospital care.
The enrollee has been asked to pay a cost share of $7,398.15 that is less than the 50% coinsurance for OON
inpatient hospital services. The services provided fall within the for OON inpatient hospital care benefit
category. Before the services were rendered, the enrollee had paid $2,538.35 total out-of-pocket. When the
enrollee was charged $7,398.15, that brought their total out-of-pocket costs to the maximum of $10,000. 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 coinsurance for the inpatient hospital services received from December
20, 2018, to December 24, 2018, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty.
You asked the Plan to pre-approve the requested services. You say that the enrollee's asthma is not well-controlled with current medications. The Plan denied your request. The Plan says there is not enough medical literature to show that the service is helpful and safe long-term.
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 pre-approve the requested services. Our physician reviewer found that the requested service is a treatment option that may reasonably be considered for those with severe persistent asthma that remain symptomatic and poorly controlled despite maximum medical therapy, including biologics. There are no clinical trial data showing efficacy and safety in patients older than 65. In addition, the records do not provide pulmonary function testing results. These are necessary both to confirm the diagnosis of asthma, and for safety reasons (FEV1 must be at least 60% predicted). For these reasons, the requested treatment is considered not medically necessary for this enrollee. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchial thermoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) for tooth # 3 provided on June 9, 2020.
You asked the Plan to pay for the dental service. You say that the provider you had been seeing for your crown build up has left the practice. You say that you were advised that the new provider's service would be covered as in network. You also say that you received a bill for over $900. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that care rendered by a provider that is not part of our supplemental dental network is not covered.
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, care rendered by a provider that is not part of the Plan's supplemental dental network is not covered. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth # 3 provided on June 9, 2020.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to waive the cost-sharing forX-Ray. We decided that the Plan does not have to waive the cost-sharing forPart B drugs and X-Ray. You asked the Plan to waive the cost-sharing forX-Ray. You say that you are appealing these cost-sharing amounts.The Plan says that the cost-sharing amounts you are being charged are correct. The Plan also says that they have reprocessed these claims at the in-network benefit level and waived the specialist visit copayments, so you are only being charged in-network cost-sharing.We decided that the Planhas to reduce the cost-sharing forX-Rayguidance provided on March 17, 2020. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $10 copayment for in-network X-Ray services. 
The Plan says you must pay $60 copayment for X-Ray guidance. Based on the Plan contract, however, you cannot be asked to pay more than $10 copayment for X-Ray guidance. Therefore, we decided that the Plan has to waive the cost-sharing forX-Ray. We also decided that the Plandoes not have to waive the cost-sharing forPart B drugs and X-Ray.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 Part B drugs and $10 copayment for X-Ray service provided by an in-network provider. The allowed amountof the Part B drugs totals$853.10, resulting in a coinsurance amount of $170.62. Therefore, your total cost-sharing responsibility is $180.62. Therefore, we decided that the Plan does not have to waive the cost-sharing forPart B drugs and X-Ray.Therefore, the Plan has to reduce your total cost-sharing responsibility from $230.62 to $180.62.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enteral formula and enteral feeding supply kit.
You asked the Plan to pre-approve these services. You say that that this is your sole source of nutrition and is
medically necessary. The Plan denied your request. The Plan says that this is not covered because you do not
have a feeding tube.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan
does not have to pre-approve enteral formula and enteral feeding supply kit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on February 24, 2020.You asked the Plan to waive the copayment forthe CT scan. Yousay that the scan was previously covered without a 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 (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 per day for Medicare-covered diagnostic radiology services.You have been asked to pay a $250 copayment for the CT scan. The 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 topay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe CT scan provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 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. 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 the medical services provided on August 17, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the compression stockings identified with code
A6534 that were issued from July 7, 2020, to August 25, 2020.
You asked the Plan to reimburse you for the compression stockings. You say that the compression socks are
needed as per your doctor's prescription. The Plan denied your request. The Plan says compression stockings
are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to reimburse you for the
compression stockings identified with code A6534 that were issued from July 7, 2020, to August 25, 2020.
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 enrollee's wound is too extensive, and medication is too expensive for care at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee does not need to see a doctor every day, or require specialty nursing 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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a chronic sacral wound. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: 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 enrollee's needs are too complex for skilled nursing care at the current facility. The Plan denied your request. The Plan says it is not likely that the enrollee requires a hospital-level care for 25 or more days.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a chronic sacral ulcer. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 co payment for the electromyography studies provided.

You asked the Plan to waive the co payment for the electromyography studies. You say that there were no additional tests given, only test results were reviewed. You say that you are disputing the bill.The Plan denied your request. The Plan says the co payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $70 copayment for each covered diagnostic procedure or test at a network doctor's office.

You have been asked to pay a $70 co payment for the electromyography studies. The electromyography studies fall 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 co payment for the electromyography studies provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided to the enrollee on April 24,2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services 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 and provide records to support the services billed. In this case, the POS code reported is not correct. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for outpatient services provided to the enrollee on April 24,2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora dental implant (D6066) provided September 9, 2020.You asked the Plan to pay forthe dental implant. You say that the services were medically necessary and should be covered.The Plan denied your request. The Plan says implants are not a covered dental benefit.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 fora dental implant (D6066) provided September 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to assignnon-covered ambulance mileage provided on June 10, 2020 to the enrollee.You asked the Plan to assignthe non-covered ambulance mileage to the enrollee. You say that that the excess mileage claim should be denied as patient liability.The Plan denied your request. The Plan says the claim was denied correctly.The Plan must follow Medicare rules. The rules state that providers may bill services with a GY modifier and the liability for the service will be assigned to the enrollee. The definition of A0888 is non-covered ambulance mileage. You did not submit the claim with the GY modifier. Therefore, we decided that the Plan does not have to assignnon-covered ambulance mileage provided on June 10, 2020 to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2752) for tooth # 29 provided on August 5, 2020.
You asked the Plan to reimburse you for the dental service. You say that the dentist advised that this service was essential to be able to chew properly. You say that you are on a small, fixed income. You also say that this is a huge situation for you. The Plan denied your request. The Plan says crowns are not a covered 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 reimburse you for the crown (D2752) for tooth # 29 provided on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for implantable defibrillator system surgery
provided on September 17, 2020.
You asked the Plan to waive the coinsurance for outpatient surgery. You say that the bill for these services is
misleading, and you should be charged a coinsurance based on a lower billed amount of $23,802.39. The Plan
denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 outpatient surgery at an outpatient hospital facility. At the time this claim was processed,
$512.16 of the $6,700 maximum out-of-pocket amount had been met. The allowed amount of this claim is
$35,526.91, resulting in a coinsurance obligation of $6,187.84 because this amount meets the $6,700 maximum
out-of-pocket amount for 2020.
You have been asked to pay 20% coinsurance for outpatient surgery, up to a $6,700 maximum out-of-pocket
amount. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital
Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the coinsurance for implantable defibrillator system surgery provided on September 17, 2020.