Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring (CGM) system.You asked the Plan to pre-approve a Dexcom G6 CGM. You say that the enrollee tried a FreeStyle Libre CGM and did not feel it was accurate.The Plan denied your request. The Plan says therecord shows the enrollee is not insulin treated three or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The enrollee has not met criteria. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve grab bars.You asked the Plan to pre-approve grab bars. You say that you have had falls in the shower and grab bars may prevent injury.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approve grab bars
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on September 11, 2019.
You asked the Plan to pay for the surgical pathology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 surgical pathology services provided on September 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services, for the enrollee. You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. 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 there is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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 LTACH services, for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and X-rays (99213, 73560, 73565) provided September 11, 2019 by physician.You asked the Plan to waive the copayment for the office visit and x-rays. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct cost-sharing was applied.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 $14 copayment per X-ray and a $30 copayment for office visits. You have been asked to pay a $42 copayment for 3 X-rays and a $30 copayment for an office visit. 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 office visit and X-rays (99213, 73560, 73565) provided September 11, 2019 by physician.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for vision care services provided on September 23, 2019 by an out-of-network provider.
You asked the Plan to waive the deductible for vision care services. You say that this was a follow-up visit and that there was an authorization in place for visits until the end of the year. The Plan denied your request. The Plan says they received a request for authorization of visits to the facility with a start date of March 12, 2019. The Plan states there were no prior requests for UVA visits. The Plan state your self-referred to UVA in December 2018. The Plan states the determination was made to approve visits to the facility as out-of-network, as these services are available from in-network physicians. The Plan states you received a Notice of Plan's Favorable Organization Determination dated March 8, 2019 advising of the authorization of visits to UVA at the out-of-network level of benefit.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The claim for your March 12, 2019 visit to UVA paid correctly as out-of-network. The claim for September 23, 2019 also paid to the out-of-network level of benefit, in accordance with the existing authorization. At the time of services rendered you had not met your $300 deductible; therefore, you have been asked to pay $109.57 for the services to apply to your deductible. 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 deductible for vision care services provided on September 23, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 18, 2019 through October 29, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that that during the procedure your lung was punctured by the operating doctor. You state that you were advised that the claim can be appealed to repair the damage caused by the doctor. You state that you should not be responsible for the copayment of $1050 due to negligence.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan states they forwarded the case to the quality of care team.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 18, 2019 and discharged on October 29, 2019. You were asked to pay a $150 copayment per day from October 18, 2019 through October 24, 2019, days 1-7 of your inpatient stay. There were no copayment charges from October 25, 2019, day 8 of your inpatient hospital care until your day of discharge October 29, 2019. Per your contract there is a $150 copayment per day required for days 1-7. 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 18, 2019 through October 29, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but your endurance level does not indicate that you can tolerate or require this on an intensive rehabilitation facility therapy program 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on September 17, 2019.
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 these services were not preauthorized or emergent. There were contract providers available to render the services at issue.
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 nursing facility care (99309) provided on September 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study described by code 95810.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95810 is not approved.The Plan must follow Medicare rules. The rules say that if the modifier indicator is 0, the Column 2 code cannot be paid regardless of whether a modifier is used.We looked at the file and Medicare rules. The Plan approved code 95811 for the enrollee. Code 95810 is a column II code with a modifier indicator of 0 when billed with column I code 95811 and cannot be approved with code 95810. The sleep study has been approved by the Plan under code 95811.Therefore, we decided that the Plan does not have to pre-approvea sleep study described by code 95810.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 11, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physician's 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 physician's services provided on October 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl 12mcg/hr patch for the enrollee.
You asked the Plan to pre-approve the patch. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part covered drugs.
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 Fentanyl 12mcg/hr patch for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee from June 27, 2019 through July 11, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says that this is not covered.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan missed the time frame and did not indicate that they would pay for the emergency services or until the enrollee was stable for transfer. The denial for no authorization is not supported.Therefore, we decided that the Plan has to pay forthe services provided to the enrollee from June 27, 2019 through July 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October
27, 2019 through October 30, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you have lost your income. You
say that you want help paying the bill. 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 $660 per
stay for each medically necessary covered inpatient stay, after you pay your $1,000 deductible.
You have been asked to pay a $660 copayment for the inpatient stay. The inpatient stay falls within 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 for the inpatient
stay provided from October 27, 2019 through October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided on November 6, 2019 to November 8, 2019.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you have met your maximum out-of-pocket amount. 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 $200 copayment per day for days 1-5 each time you are admitted to an acute cute hospital. You have been asked to pay a $200 copayment for each day of the inpatient hospital stay. ($200 x 2 = $400). The inpatient hospital stay falls within "Inpatient hospital care" benefit category. The record shows you had not yet met your maximum out-of-pocket amount.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 inpatient stay provided on November 6, 2019 toNovember 8, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90791, 90853, 90832, 90847) provided on June 19, 2019 to July 5, 2019. You asked the Plan to pay for the outpatient mental health service. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were in-network providers that could render the services at issue.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 outpatient mental health services (90791, 90853, 90832, 90847) provided on June 19, 2019 to July 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer with compression and supplies provided on October 15, 2019 by an out of network provider. You asked the Plan to pay for the nebulizer with compression and supplies provided by an out of network provider. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 for the nebulizer with compression and supplies provided on October 15, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on September 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient lab work. You say that the urine test was medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained.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 outpatient lab work provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forchiropractic services provided by an out-of-network provider, on August 21, 2019 to November 13, 2019.You asked the Plan to waive the copayment forchiropractic services. You say that you do not understand why you used to pay $20and now have to pay $50 a session.The Plan denied your request. The Plan says the correct copayment has been applied.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 $50 copayment for chiropractic services/out-of-network. You have been asked to pay a $50 copayment for chiropractic services. is no longer in-network; therefore, the correct copayment has been applied. Chiropractic services falls within the chiropractic services/out-of-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 forchiropractic services provided by an out-of-network provider, on August 21, 2019 to November 13, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued attendant care services (S5125).
You asked the Plan to pre-approve continued attendant care services. You say that the enrollee cannot take care
of herself without supervision. The Plan denied your request. The Plan says these services are not medically
necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of continued attendant care services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued attendant care services (S5125).