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

We decided that the Plan does not have to pay forthe nerve analysis rendered to the enrollee on July 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of diagnostic services when furnished in a different payment locality than the TC.The provider submitted a claim for procedure code 88356-26. The file does not show that the PC was performed in a different payment locality thanthe TC.Therefore, we decided that the Plan does not have to pay forthe nerve analysis rendered to the enrollee on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Chantix Pak 0.5 & 1mg.
You asked the Plan to pre-approve Chantix. You say that the Chantix is medically necessary. The Plan denied your request. The Plan says coverage is not available for this drug under the Part B Medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Chantix Pak 0.5 & 1mg.
Benefits for Chantix may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on September 19, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. The provider submitted a claim for procedure code 99285 with diagnosis code F01.50 as the primary diagnosis. This diagnosis code is not appropriately billed as a primary diagnosis. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 13, 2019 through September 30, 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 due to the quality of care 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 were admitted on September 13, 2019 and discharged on September 30, 2019. You were asked to pay a $275 copayment per day from September 13, 2019 through September 17, 2019, days 1-5 of your inpatient stay. There were no copayment charges from September 18, 2019, day 6 of your inpatient hospital care until your day of discharge September 30, 2019. Per your contract there is a $275 copayment per day required for days 1-5. 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 from September 13, 2019 through September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroxygen concentrator (CPT Code E1390RR) provided on May 10, 2019, by an in-network provider.You asked the Plan to waive the coinsurance forthe DME. 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 show that you received an oxygen concentrator (CPT Code E1390RR) provided on May 10, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME. 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 foroxygen concentrator (CPT Code E1390RR) provided on May 10, 2019, by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 2, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 Plandid not pre-approve the laboratory services.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 laboratory services provided on September 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forradiation therapy provided from February 1, 2019 through February 28, 2019.You asked the Plan to waive the coinsurance forradiation therapy. You submitted your bills for review. You say that you are appealing the additional charge.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 radiation therapy service. You have been asked to pay a total of $1,369.99, which is less than the standard 20% coinsurance for radiation therapy because you met your maximum out-of-pocket. Radiation therapy 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 coinsurance forradiation therapy provided from February 1, 2019 through February 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the upper GI endoscopy provided on October 1, 2019.
You asked the Plan to reduce the copayment for the upper GI endoscopy. You say that that service was done at a free-standing clinic and you should not be charged the extra $100. 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 $325 copayment for an outpatient hospital facility. You have been asked to pay a $325 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the facility is not a free-standing clinic and you were billed by the outpatient hospital
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 reduce the copayment for the upper GI endoscopy provided on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is noted to have multiple aches and pains due to multiple conditions. While the enrollee is noted to have knee pain, it is unclear that osteoarthritis is the primary source of her knee pain. As such, it is not clear that Synvisc is reasonable and medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided to the enrollee from February 27, 2019 through March 23, 2019.
You asked the Plan to waive the copayment for SNF care. You say that no one told you that the enrollee would be charged for a longer stay. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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 the enrollee was admitted on February 27, 2019 and was discharged on March 23, 2019. There were no copay charges for the first 20 days (February 27, 2019 through March 18, 2019). The enrollee was asked to pay a $100 copayment per day for SNF services provided from March 19, 2019, their 21st day of SNF care through March 22, 2019. The enrollee was discharged on March 23, 2019 and there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $100 copayment required for days 21-100. 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 SNF care provided to the enrollee from February 27, 2019 through March 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 21, 2018 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 by a non-plan 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 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 forthe medical services provided on November 21, 2018 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient hospital services from June 3, 3019 to June 8, 2019 by the out of area provider.You asked the Plan to pay forthe inpatient hospital services. The Plan denied your request. The Plan says that that the services were not urgent. The Plan also says authorization was not obtained before the services were provided to the enrollee.Medicare says that plans must pay foremergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.  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 inpatient hospital services. Our reviewer says that the services were medically necessary. Our physician reviewer found that the records show the enrollee presented with 10-days of symptoms concerning for worsening coronary ischemia while out of the service area. In this circumstance, new or worsening symptoms in spite of medical therapy is highly suggestive of an unstable coronary syndrome that warrants urgent evaluation and treatment. The records indicate the care provided was medically necessary. Based on the enrollee's symptoms, it would not have been medically reasonable to delay care for up to 6 months until the patient returned to his service area. Finally, based on the records the enrollee could not have foreseen requiring this evaluation and treatment prior to leaving his service area.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 inpatient hospital services have been met.Therefore, we decided that the Plan has to pay forthe inpatient hospital services from June 3, 3019 to June 8, 2019 by the out of area provider. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 24, 2019 through September 27, 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 were admitted on September 24, 2019 and discharged on September 27, 2019. You were asked to pay a $360 copayment per day from September 24, 2019 through September 26, 2019, days 1-3 of your inpatient hospital care. You were discharged on September 27, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $360 copayment per day required for days 1-5. 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 from September 24, 2019 through September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilation system
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says there is no documentation that the enrollee has chronic respiratory failure.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 items. Our physician reviewer found that the enrollee has been on a ventilator since April 2019, at night only, in BiPAP mode. There is a reported diagnosis of COPD and heart failure, but no clinical documentation of chronic respiratory failure. There are no pulmonary function data to confirm or determine severity of COPD. There are no arterial blood gas data to confirm hypercarbia. There are no data indicating failure of BiPAP, or even need for BiPAP. Therefore, the medical necessity of a home ventilator has not been established. 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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve a ventilation system
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Chantix Pak 0.5 & 1 mg medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Chantix Pak 0.5 & 1 mg medication.
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the screening is medically necessary.The Plan denied your request. The Plan says coverage criteria for a LDCT Lung Cancer screening has not been met, but the plan may approve a CT Scan of the Chest (71250) if requested.The Plan must follow Medicare rules. Medicare rules say that for a LDCT Lung Cancer Screening to be covered the enrollee must be between ages 55 and 77 and be asymptomatic. We looked at the file and Medicare rules. The Enrollee is older than 77. The enrollee has a history of pleural nodules and therefore is not asymptomatic. Based on this information, we decided that Medicare rules for coverage of the LDCT Lung Cancer Screening have not been met.Therefore, we decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 11, 2019 through October 16, 2019 provided by an in-network provider.
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 were admitted on October 11, 2019 and discharged on October 16, 2019. You were asked to pay a $345 copayment per day from October 11, 2019 through October 15, 2019, days 1-5 of your inpatient hospital care. You were discharged on October 16, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $345 copayment per day required for days 1-5. 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 from October 11, 2019 through October 16, 2019 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 22, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to payfor these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the prophylaxis (D1110), and the periapical x-ray (D0220) provided on July 24, 2019.You asked the Plan to pay forthe dental services. You say that the provider's office never called in to verify that the services were covered by the Plan. You also say that now you are penalized with a bill.The Plan denied your request. The Plan says the oral evaluation, prophylaxis, and x-ray are not listed as covered services.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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the prophylaxis (D1110), and the periapical x-ray (D0220) provided on July 24, 2019.