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

We decided that the Plan does not have to reduce the coinsurance forthe CT imaging procedure provided on June 13, 2019.You asked the Plan to reduce the coinsurance forthe CT imaging procedure. You say that you should be charged the in-network rate for the procedure.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 withthe Plan clearly says that you must pay 40% coinsurance for advanced imaging services at an out-of-network outpatient hospital. You have been asked to pay $127.42 which is 40% of the allowed amount for the CT imaging procedure. The allowed amount is $318.55. ($318.55 x 40% = $127.42). The CT imaging procedure falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the provider is out-of-network.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 coinsurance forthe CT imaging procedureprovided by on June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be taken care of in a skilled nursing facility, or at home with home health services.
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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from PT and OT but the documentation does not indicate that the enrollee requires or can tolerate this therapy on an intensive level in an IRF. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on October 10, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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. 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 physician services provided on October 10, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
You asked the Plan to pre-approve percutaneous vertebral augmentation. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is covered when all of the above criteria are met. 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 percutaneous vertebral augmentation. Our reviewer says that the requested percutaneous vertebral augmentation is not medically reasonable and necessary. Our physician reviewer found that the enrollee has been recommended to undergo percutaneous vertebral augmentation for a compression fracture in her thoracic spine. Per the applicable LCD, this service may be covered when all of the requirements in the LCD have been met. In review of the records provided, there was no indication of a "Multidisciplinary team consensus" for performance of the PVA. Rather, the plan of care presented was done solely by rendering provider. This would indicate that the requirements for coverage have not been met and this service would not be medically 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 percutaneous vertebral augmentation have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebral augmentation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided July 22, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that please review and issue a retro authorization for this claim.The Plan denied your request. The Plan says the records do not support that the inpatient admission was medically reasonable and 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the ED early on 7/22/2018 after falling down the stairs. She was evaluated by the ED staff and the trauma service and found to have no significant injuries. While furthering monitoring was reasonable, this monitoring could have occurred with the enrollee on observation status. The treating providers had all day 7/22 and 7/23 to monitor the enrollee before deciding if two midnight of care (7/22-24) would be medically necessary. As is, the enrollee was discharged later on 7/22 having spent no midnights in the hospital. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided July 22, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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. 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 laboratory services provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Magnetic Resonance Imaging (MRI) of the lower extremities (73718, 73721) provided October 23 and November 12, 2019.
You asked the Plan to waive the copayments for the MRI's. You say that the copayments should be waived because the provider failed to capture the correct section of the lower extremity in the first image. The Plan denied your request. The Plan says the correct copayments were applied. A copayment is assessed if the service is performed, regardless of outcome.
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 for Advanced Radiology Services. You have been asked to pay $150 copayments for the MRI's. The MRI's fall within the Advanced Radiology Services 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 copayments for Magnetic Resonance Imaging (MRI) of the lower extremities (73718, 73721) provided October 23 and November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relion Prime diabetic testing strips.
You asked the Plan to pre-approve Relion Prime test strips. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because Relion Prime is not a preferred brand of testing strips for this Plan and the enrollee can use one of the Plan's preferred brands such as Accu-Check.
The Plan must follow Medicare rules. Medicare rules say that health plans may specify preferred brands and manufacturers and limit supply to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items. We looked at the file and Medicare rules. Relion Prime is not a preferred brand for this Plan and is not generally covered. The enrollee can use a preferred brand for these supplies. Based on this information, we decided that Medicare rules for coverage of Relion Prime test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Relion Prime diabetic testing strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397, L2810) provided to the enrollee on October 17, 2019.
You asked the Plan to pay for the orthoses. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."] The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397, L2810) provided to the enrollee on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on March 12, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on March 12, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on November 5, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that please reprocess this claim for payment.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 subsequent nursing facility care (99308) provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 7, 2019 through November 14, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were under the impression that you were under observation status the whole time. 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 November 7, 2019 and discharged on November 14, 2019. You were asked to pay a $300 copayment per day from November 7, 2019 through November 12, 2019, days 1-6 of your inpatient stay. There were no copayment charges from November 13, 2019, day 7 of your inpatient hospital care until your day of discharge November 14, 2019. Per your contract there is a $300 copayment per day required for days 1-6. 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 November 7, 2019 through November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for travel and lodging expenses provided October 24, 2019.
You asked the Plan to pay for the travel and lodging expenses. You say that the mileage is related to pre-transplant procedures. The plan paid mileage for your visits on 8/22/19 and 10/09/19 and now the mileage is being denied. The Plan denied your request. The Plan says this request is not covered under the plan benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover for travel and lodging expenses. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Under certain conditions the plan will arrange or pay for appropriate lodging and transportation costs for you and a companion when you choose to seek in-network transplant services outside of the service area. The records show that the enrollee was triaged by nurses and seen for gastric varices by a gastroenterologist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have to pay for travel and lodging expenses provided October 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 19, 2019 to October 18, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided September 19, 2019 to October 18, 2019.
Appeal type: DME/ Orthotics
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 pneumatic compression device. You say that this is the only provider in the area that supplies the requested items. The Plan denied your request. The Plan says the denial of authorization for these items is correct, because this provider is out-of-network with the Plan and this pneumatic compression device can be obtained from an in-network supplier.
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 care that cannot be provided by network providers. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 3, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you cannot afford the 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 $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance Services" 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 ambulance ride provided on October 3, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the lung ventilation and perfusion imaging service provided on October 3, 2019.
You asked the Plan to pay for the lung ventilation and perfusion imaging service. You say that the provider is not paid by hospice and the service is not related to the hospice diagnosis. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows the patient was enrolled in hospice from September 7, 2019 to October 2, 2019. However, Medicare is still responsible for payment until the start of the next month after revocation. Therefore, we decided that the Plan does not have to pay for the lung ventilation and perfusion imaging service provided on October 3, 2019.