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 from June 7, 2019 through June 12, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received inpatient hospital care from June 7, 2019 through June 12, 2019. You were asked to pay a $375 copayment per day from June 7, 2019 through June 10, 2019, days 1-4 of your inpatient hospital care. There were no copayment charges from June 11, 2019, day 5 of your inpatient hospital care until your day of discharge June 12, 2019. Per your contract there is a $375 copayment per day required for days 1-4. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 7, 2019 through June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator provided on September 30, 2019 by out of network provider.You asked the Plan to pay for the portable oxygen concentrator. You say that you need the portable oxygen concentrator to go to the store and travel.The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network provider. 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 portable oxygen concentrator provided on September 30, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON primary care services. You say that the enrollee has been under your care for some time and you have left the network and cannot participate in her network at this time. She wishes to continue care with you and you feel that this OON should be approved. The Plan denied your request. The Plan says while the enrollee does medically require primary care services, this can be provided by a network internal medicine provider. There is no evidence that this
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care from August 25, 2019 through August 26, 2019 provided by an out-of-network provider.You asked the Plan to pay forinpatient hospital care. You say that you feel like you saved the Plan money.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 forinpatient hospital care from August 25, 2019 through August 26, 2019 providedby an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran echocardiography provided on October 1, 2019 by the out of network provider. You asked the Plan to pay foran echocardiography. You say that you are requesting reconsideration of payment for these services.The Plan denied your request. The Plan says no prior authorization was obtained for the services. The Plan says that there are multiple in-network providers within 30 miles of the member's residence that could have rendered these services.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 anetwork 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 theseitems/services.Therefore, we decided that the Plan does not have to pay foran echocardiography provided on October 1, 2019 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on September 10, 2019. You asked the Plan to waive the copayment for the colonoscopy. You say that this should be billed as preventive. You say that there should be no 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 $300 copayment for outpatient surgery at a free standing ambulatory surgical center. You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered due to rectal bleeding, which is considered diagnostic. 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 diagnostic colonoscopy provided on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the records indicate this enrollee is now status post partial sacrectomy for sacral chordoma with large biopsy confirmation, and S2-3 laminectomy on 1/16/2020. Current records indicate the enrollee is afebrile, and hemodynamically stable post-op. There is no significant anemia. The records indicate as of 1/28/2020 the enrollee is minimal assist to standby assist for mobility, and ambulation x 200 feet. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal/standby assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the occlusal guard.You asked the Plan to pre-approve the occlusal guard. You say that your current mouth guard doesn't fit. You say that you need a new one.The Plan denied your request. The Plan says this is not a covered 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 pre-approvethe occlusal guard
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for removal of a central venous access device (CPT Code 36589) provided on September 10, 2019.
You asked the Plan to waive the copayment for the services. You say that the PICC line was supposed to be removed by the Home Health nurse, but she was afraid to try too much because it was a little difficult for her. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received outpatient hospital facility services on September 10, 2019. Therefore, you are asked to pay a $325 copayment for the 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 removal of a central venous access device (CPT Code 36589) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on November 8, 2019.
You asked the Plan to pay for the office visit. You say that you were not aware that the provider would bill an office visit which would deny as non-covered. The Plan denied your request. The Plan says per the EOC; only manual manipulation is a covered chiropractic service.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit (99203) provided on November 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 12, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were made to believe that the CT scan was necessary and that insurance would cover it. You say that you may have opted out if you knew it was optional. 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 $100 for each Medicare-covered diagnostic radiology service from an in-network provider. You have been asked to pay a $100 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 to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on September 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by out of network provider.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the physician is out of network and the plan has in-network providers that could provide the services at issue. The services were not emergent or pre-authorized.
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 medical services provided on August 6, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 16,
2019 at 12:30pm through June 18, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 hospital care. Our physician
reviewer found the review has determined that the enrollee was hemodynamically and neurologically stable
and appropriate or ambulance transport with monitoring to a Plan facility as of 12:30pm on June 16, 2019.
There was no documentation provided necessitating post- stabilization care services June 16, 2019 at 12:30pm
through June 18, 2019 at the nonPlan facility. The review has determined that the treating physician did not
document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any
dates of service.
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 hospital care have not been met. Therefore, we decided that the Plan
does not have to pay for inpatient hospital care provided to the enrollee from June 16, 2019 at 12:30pm through
June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider, on July 22, 2019.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the services were rendered by an out of network provider 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 provider and the facility in this case are not network providers 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 by the out of network provider on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650), a shoulder-hand-wrist orthosis (L3960), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 31, 2019.You asked the Plan to pay forthe orthoses. You say that the claim shouldbe paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a coveredservice under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650), a shoulder-hand-wrist orthosis (L3960), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on January 31, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran endoscopy provided on September 16, 2019 by the out of network provider. You asked the Plan to pay foran outpatient surgery. You say that you have attached medical records and would like this claim reviewed.The Plandenied your request. The Plan says the member's primary care physician did not refer these services.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 foran endoscopyprovided on September 16, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs physical therapy that can only be offered in a skilled nursing facility. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not show that the enrollee has any identified skilled nursing needs. While the enrollee has skilled therapy needs, the enrollee does not need skilled therapy on a daily basis. The frequency of skilled therapy treatment recommended in the supplied records is three times a week. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services provided from June 19, 2018 through June 20, 2018.
You asked the Plan to waive the copayment for the services. You say that you did not go in for mental health. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received emergency care and inpatient mental health care from June 19, 2018 through June 20, 2018. You are asked to pay a $100 copayment for emergency care and a $900 copayment for inpatient mental health care. 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 services provided from June 19, 2018 through June 20, 2018.