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

We decided that the Plan does not have to waive the copayment forthe inpatient hospital care provided from July 13, 2020, to July 20, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that you feel like you should not have to pay the copayment.The Plan denied your request. The Plan says the copayment processedcorrectly in this case.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 per day for days 1-6, $0 copayment after day 6 for inpatient hospital care. You have been asked to pay a total cost share of $1950for the inpatient hospital care($325 copayment x 6 days). The services provided fallwithin the inpatient hospital care 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 forthe inpatient hospital care provided from July 13, 2020, to July 20, 2020.Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot addressquality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that there are no in-network doctor that can treat patients in this facility. The Plan denied your request. The Plan says a prior authorization is required for out-of-network services that are not urgent or emergent.
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 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 July 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.
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 had network providers available who could have provided 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 physician services provided on September 11, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveparenteral nutrition.You asked the Plan to pre-approvethe requested services. You say that the enrollee is incapable of meeting her nutritional needs solely with tube feeding.The Plan denied your request. The Plan says the services are covered for three months.The Plan must follow Medicare rules. The rules say that coverage of parenteral nutrition therapy must be approved at periodic intervals of no more than three months.We looked at the file and the rules.The Plan has agreed to pre-approve threemonths of parenteral nutrition. Medicare only covers the requested services at intervals of three months. Therefore, we decided that the Plan does not have to pre-approveadditional parenteral nutritionat this time
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora change of cystostomy tube (51705) provided on May 5, 2020, through August 25, 2020.You asked the Plan to waive the copayment forcatheter replacement. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $50 copayment for outpatient surgery.You have been asked to pay a $50 copayment for catheter replacement. Catheter replacement falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment fora change of cystostomy tube (51705) provided on May 5, 2020, through August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fororthoses provided to the enrollee on August 27, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay fororthoses provided to the enrollee on August 27, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea protective outer surface covering system (L5962) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe documentation does not show special needs for protection against unusually harsh environmental situations.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 services. Our reviewer says that the requested services arenot considered medically reasonable and necessary in this case. Our physician reviewer found there are no special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704, L5705, L5706, and L5707.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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea protective outer surface covering system (L5962) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychiatric evaluation provided on February 21, 2019.You asked the Plan to pay forthe psychiatric evaluation. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the claim was submitted untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the psychiatric evaluation was not filed until September 8, 2020.. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe psychiatric evaluation provided on February 21, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodic oral evaluation (D0120), preventative procedure (D1999) and prophylaxis -adult (D1110) provided on June 2, 2020.You asked the Plan to pay fororal evaluation, preventative procedure and prophylaxis. You say that the services should be covered.The Plan denied your request. The Plan says the services were provided after your coverage had ended.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forperiodic oral evaluation (D0120), preventative procedure (D1999) and prophylaxis -adult (D1110) provided on June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient hospital services provided on May 29, 2020.You asked the Plan to pay forthe outpatient hospital services. The Plan denied your request. The Plan says this service required 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 withthe Plan. The Plandid not pre-approve the item/service 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 foroutpatient hospital services provided on May 29, 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. The Plan denied your request. The Plan says the
enrollee's care is not complex enough.
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 LTACHs are certified as acute care hospitals, and in general, do not provide clinical services
that are materially different than those of short term acute care hospitals. In this case, ongoing care needs
include oxygen supplementation, nebulizer treatments, surveillance laboratory studies, coccyx wound care, and
therapy services. The documentation does not support that the enrollee in this case requires services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fororal exam (D0150) and crown (D2740) provided on July 29, 2020.You asked the Plan to pay forexam and crown. You say that the service should be covered.The Plan denied your request. The Plan says if you see an out-of-network dentist, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. You are responsible for the difference between the INFS and dentists' charged fees when visiting an out-of-network dentist.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. Specifically, you received care from an out-of-network provider. You are responsible for any cost that goes over the in-network cost.Therefore, we decided that the Plan does not have to pay fororal exam (D0150) and crown (D2740) provided on July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee is stable and will require extended acute care.The Plan denied your request. The Plan says the request for approval of admission to a LTACH does not meet the requirements for approval.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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our reviewer found that there are no required medical services identified thatare available at the LTACH, that are not available at the current health care setting being offered by the Plan. Our physician reviewer also found that consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate forthe diagnosis and condition of the enrollee 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe domiciliary visit provided on July 30, 2020 by an out of network (OON) provider.You asked the Plan to pay fordomiciliary visit. You say that you provided medically necessary services in good faith.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered byan 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, outof area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 domiciliary visit provided on July 30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic office visit (CPT 99201) services received on August 24, 2020.You asked the Plan to pay forthe office visit. You say that you shouldn't have to pay for this.The Plan denied your request. The Plan says these services are not covered by Medicare.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 forchiropractic office visit (CPT 99201) services received on August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the macular degeneration genetic testing provided on January
28, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were not
medically necessary.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that a buccal swab screening for macular degeneration was performed at the time of cataract surgery.
There are no records submitted with justification for the screening based on findings or risk.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the macular degeneration genetic testing provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two problem focused limited oral evaluations, preventive procedure, three crowns, and first intraoral periapical x-ray provided on September 3, 2020, and September 14, 2020.You asked the Plan to pay forthe problem focused limited oral evaluations, preventive procedure, crowns, and first intraoral periapical x-ray. You say that these services were for medically necessary dental services, and should be covered.The Plan denied your request. The Plan says the problem focused limited oral evaluations, preventive procedure, and crowns are not covered benefits. The Plan also says that your benefits for the first intraoral periapical x-ray had been satisfied and the frequency limitation had been exceeded.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 offersa dental benefit in excess of Medicare coverage, the problem focused limited oral evaluation, unspecified preventive procedure, and crown are not among those covered under this benefit. The Plan contract also says that intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on September 3, 2020, and your intraoral x-rays benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe two problem focused limited oral evaluations, preventive procedure, three crowns, and first intraoral periapical x-ray provided on September 3, 2020, and September 14, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waivethe cost share charged for outpatient surgery, Medicare Part Drugs, self-administered drugs and imaging provided from June 20, 2018 to June 21, 2018.You asked the Plan to waivethis cost share. You say that you think the Plan,or the provider should waive this $339.99 cost share because they took so long to bill you.You also state that you were treated as inpatient not outpatient because you stayed overnight. The Plan denied your request. The Plan says they have paid their portion of this claim and the remaining cost share is your contractual agreement based on the services provided and the Medicare allowable rates for those services.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 cost share for each outpatientservice provided. Based onreview of the claims both you and the Plan provided, you were not an inpatient status claim for this service. This was billed as an outpatient surgery. Typically,you would be charged a $275 copayment for outpatient surgery, a $20 copayment for the x-ray, an $84.99 coinsurance (20%) for the Medicare Part B drugs, and $4.50 for self-administered drugs, that would be submitted to your Medicare Part D carrier. The total of these charges is $384.49 for these services. Therefore, the $339.99remaining is actually less than your contractual cost share for these services.  
You have been asked to pay less than the normal copayment expectation based on your 2018 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 waivethe cost share charged for outpatient surgery, Medicare Part Drugs, self-administered drugs and imaging provided from June 20, 2018 to June 21, 2018
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for routine transportation trips (A0170).You asked the Plan to pre-approveadditional mileage for routine transportation trips. You say that the additional mileage is needed.The Plan denied your request. The Plansays the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria has not been met.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers unlimited one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles per trip.We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional mileage for routine transportation trips (A0170).