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

We decided that the Plan does not have to pre-approve a stabilizer bar, side guards, and medium flat hand pad for a manual wheelchair 
You asked the Plan to pre-approve these services. You say that the enrollee has a fractured neck and seizures and is unable to ambulate. The Plan denied your request. The Plan says the items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a stabilizer bar, side guards, and medium flat hand pad for a manual wheelchair
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. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 they are 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 21, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that the insurance should not pay this claim because nothing was done. You say you took several tests and anx-ray but were told nothing was wrong. 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 ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $80 copayment for in-and out-of-network Medicare-covered emergency room visits. You have been asked to pay a $80 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room 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 an emergency room visit provided on September 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ferumoxytol (Q0138).You asked the Plan to pre-approveferumoxytol. You say that ferumoxytol is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.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 ferumoxytol. Our reviewer says that the ferumoxytol is not medically necessary. Our physician reviewer found review of the documentation does not support the diagnosis of anemia, failure of oral supplementation, or a diagnosis of renal disease.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ferumoxytol have not been met.Therefore, we decided that the Plan does not have to pre-approveferumoxytol (Q0138).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on October 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for pathology services. You say that the patient's healthcare provider took the specimens at their office and sent them to our laboratory for analysis. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 pathology services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable ventilator.You asked the Plan to pre-approvethe requested ventilator. The Plan denied yourrequest. The Plan says Medicare does not cover a ventilator to help breathing at various times of the day.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 ventilator. Our physician reviewer found that you have severe COPD, requiring oxygen supplementation. However, carbon dioxide (CO2) retention has not been documented with an arterial blood gas. The ventilator is requested at settings that can be delivered by certain BiPAP devices. Medicare does not cover home ventilators when used as BiPAP devices. Therefore, a home ventilator is considered not 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 the requested ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approvea portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for fluid removal provided on October 16, 2019.You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with these charges.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 $125 copayment for outpatient surgery/Plan I/in-network. You have been asked to pay a $125 copayment for an outpatient surgery. The service that was provided is considered an outpatient surgery. An outpatient surgery falls within the outpatient surgery/Plan I/in-network 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 fluid removal provided on October 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the laser eye surgery provided on November 15, 2019.
You asked the Plan to waive the copayment the laser eye surgery. You say that the laser treatment was administered as a result of cataract surgery in 2018. You say you should not be responsible for 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 $30 copayment for Medicare-covered visits with an in-network specialist. You have been asked to pay a $30 copayment for the laser eye surgery. The laser eye surgery falls within the Medicare-covered visits with an in-network specialist benefit category. The record shows the laser eye surgery is considered a separate procedure.
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 the laser eye surgery provided on November 15, 2019.v
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond March 22, 2020.
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 continued services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the SNF on February 14, 2020 after a hospitalization for heart failure. The records show that you do not have any skilled nursing needs. You do not require skilled nursing or skilled therapy on a daily basis. As a practical matter, you no longer require the necessary services on an inpatient basis at the SNF level of care. 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-approve continued skilled nursing facility (SNF) services beyond March 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 19, 2019.You asked the Plan to waive the copayment for the office visit. You say that you do not want to pay.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network specialist office visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay forthe medical services provided to the enrollee by an out-of-network provider on June 25, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan has to pay forthe medical services provided to the enrollee by an out-of-network provider on June 25,2019.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on May 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not received.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the services provided on May 6, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on February 18, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you did not go outside the
parameters of the wellness exam. You say that you believe the doctor billed incorrectly. The Plan denied your
request. The Plan says that the copayment applied correctly.
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 2019 Evidence of Coverage was not submitted. This means that the Plan has
not shown that the copayment amount you are being asked to pay is correct or justified by the health plan
contract. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on
February 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on September 12, 2019.
You asked the Plan to waive the copayment for these services. You say that you shouldn't be billed for services that didn't work. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for Medicare-covered outpatient hospital surgery services.
The file shows that you received outpatient surgical services in the form of injections on September 12, 2019. You have been asked to pay a $400 copayment for these services. These services fall within the Medicare-covered outpatient hospital surgery 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 outpatient surgical services rendered to you on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiation treatment and radiation physician consultation provided on November 19, 2019 and November 20, 2019.You asked the Plan to waive the copayment for the radiation treatment and radiation physician consultation. You say that the cost is a lot. You say that you want help with the copayment.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service.You have been asked to pay a $60 copayment for the radiation treatment and a $60 copayment for the radiation physician consultation. The radiation treatment and radiation physician consultation falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the radiation treatment and radiation physician consultation provided on November 19, 2019 and November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 30, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug services rendered to you on October 29, 2019.You asked the Plan to waive the coinsurance for these services. You say that you weren't told about the coinsurance.The Plan denied your request. The Plan says the coinsurance was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each in-network Medicare-covered Part B drug. Review of the file shows that you received Part B drug injections on October 29, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the in-network Medicare-covered Part B drug 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 for the Part B drug services rendered to you on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant 360 testing provided on November 18, 2018.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this was 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 the enrollee has a diagnosis of breast carcinoma with metastasis. A progress note dated November 5, 2018, notes a plan to order a Guardant liquid biopsy which was declined by the enrollee. The test was subsequently submitted on November 9, 2018. The records do not outline the rationale for test or the management plan related to test. Without the support of the documentation, medical necessity cannot be determined. 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 Guardant 360 testing provided on November 18, 2018.