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

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided December 30, 2020 to January 7, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that the plans have always paid for your claims. You cannot afford to pay what you were charged. The Plan denied your request. The Plan says the claim was processed and the correct copayment applied per the Evidence of Coverage.
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 $350 copayment per day, days 1-6 for Inpatient hospital care. You have been asked to pay $2,100 ($350 x 6 days) for the inpatient services. The inpatient services fall 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 hospital services provided December 30, 2020 to January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits and a visual function screening to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network vision services. You say that the provider in question took over the practice for the previous provider you saw, and you would like to continue to receive care at this practice. You have a medical condition and take medication that you used to receive from this provider. The Plan denied your request. The Plan says there are other in-network providers who would be able to safely provide and take over this care. In addition, a visual function screening is not covered by Medicare, and the Plan's supplemental benefit rules state that routine vision services must be provided by the Plan's specified routine vision 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, out of area urgent care and pre-approved care. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided by the Plan's specified in-network vision provider.
The provider at issue in this case is not a network provider with the Plan. 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 vision services provided by an out-of-network provider. Our reviewer says that the provided records do not indicate why you cannot see an in-network provider. Our physician reviewer found that the medical necessity and reasonableness of the requested services, as defined by Medicare rules, is not established. The requested care can be safely transferred to an in-network provider. In addition, the elements of the Plan's coverage rules are not satisfied, as a visual function screening is not a Medicare-covered benefit and must be provided by a provider in the Plan's specified routine vision network.
We looked at this physician's review, the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the out-of-network vision services have not been met. Therefore, we decided that the Plan does not have to pre-approve office visits and a visual function screening to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy evaluation services coded 97163
provided on May 8, 2020.
You asked the Plan to pay for the physical therapy evaluation services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 97163 is physical therapy evaluation: high complexity,
requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities
that impact the plan of care; An examination of body systems using standardized tests and measures addressing
a total of 4 or more elements from any of the following: body structures and functions, activity limitations,
and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. We find that CPT code 97163 is not supported in the medical record. Specifically, the documentation indicates that these services were performed by a qualified physical therapist in the home health setting. This means there is a more appropriate code to be billed for these services. Based on this information, we decided that Medicare rules for coverage of the physical therapy evaluation services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy evaluation services coded 97163 provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on February 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are available in-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 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 for the services provided to you by an out-of-network provider on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on December 28, 2020.

You asked the Plan to waive the coinsurance for an office visit. You say that you should not have an out-of-pocket expense for this visit. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

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 physician/practitioner services, including doctor's office visits.

You have been asked to pay a 20% coinsurance for an office visit. The EOC confirms 20% is the required coinsurance for this service. The record shows that the Plan approved a cost-share amount of $15. An 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 coinsurance for an office visit (99213) provided on December 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found your condition does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Wound vac change is every 3 days. You were off of IV antibiotics on June 8, 2020. The current functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. Skilled nursing or skilled therapy services (or a combination of these services) are not required on a "daily basis" in a SNF beyond the last covered date. Medicare coverage criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast reduction surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve breast reduction surgery. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested services can be provided by an in-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 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 breast reduction surgery to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from April 17, 2020, to May 8, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that you feel that the Plan should pay for these services. The Plan denied your request. The Plan says the enrollee was under hospice care until April 17, 2020, and was discharged back to hospice on May 8, 2020.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on April 17, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from April 17, 2020, to May 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy services provided on November 23, 2020.
You asked the Plan to waive the coinsurance for chemotherapy services. You say that you do not know why the enrollee is being charged the amount at issue. The Plan denied your request. The Plan says the correct coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Part B drugs, including chemotherapy drugs. The enrollee has been asked to pay $1,893.54, or less than 20% of the Medicare-allowed amount of $2,442.55, for chemotherapy services. Chemotherapy services fall within the "Medicare Part B prescription drugs" benefit category. This means that the enrollee has been asked to pay less than or equal to the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon
enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy services provided on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic panel testing.
You asked the Plan to pre-approve genetic testing. You say that your treating physician ordered this testing, therefore it must be needed for your upcoming treatment. The Plan denied your request. The Plan says the denial of authorization for this testing is correct because this testing is not FDA-approved or clear for use in your condition.
The Plan follows Medicare rules. Medicare rules state that Next Generation Sequencing (NGS) genetic testing may be covered under certain conditions. 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 genetic testing. Our reviewer says that you do not meet the Medicare criteria for the requesting genetic testing. Our physician reviewer found the documentation does not support that you have recurrent, relapsed, refractory, metastatic, or advanced Stage III or Stage IV cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic panel testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on January 19, 2021.
You asked the Plan to pay for the crown. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 23650) provided to the enrollee on May 8, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code has an MUE value of 1, but 2 units were billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 23650 is "Closed treatment of shoulder dislocation, with manipulation." 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 services. Our reviewer says that the services at issue in this case were supported by the medical records. Our physician reviewer found the CPT code 23650 has an MUE of 1 indicating that bilateral procedures are adjusted for payment and not billed separately. In this case, the provider billed CPT 23650-54-LT-59 and CPT 23650-54-RT. The 23650 code has an MUE of 1 for bilateral procedures. Each procedure was billed separately. The coverage criteria are not
satisfied. 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 Plan does not have to pay for surgical services (CPT 23650) provided to the enrollee on May 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
March 5, 2020 to March 16, 2020.
You asked the Plan to waive the copayment for the inpatient services. You say that all bills have been taken
care of until you received a charge of $1,650. You have never received this charge for any other emergency,
and you question why now. The Plan denied your request. The Plan says the claim was processed correctly per
the Evidence of Coverage
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 $275
copay for days 1-6 for Inpatient hospital care.
You have been asked to pay $1,650 ($275 x 6 days for the inpatient services. Tthe inpatient services fall 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 hospital services provided March 5, 2020 to March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller and harness for a Group 3 power wheelchair.

You asked the Plan to pre-approve expandable controller and harness. You say that the enrollee needs these power wheelchair accessories. The Plan denied your request. The Plan says the denial of authorization for these components is correct, because the approved power wheelchair does not have any power seating options so these upgraded electronics are not needed.

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 expandable controller and harness. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices or non-proportional input devices. The enrollee does not need to operate 3 or more power seating actuators through the drive control, a separate display, other electronic devices, or an attendant control. The enrollee's strength in the upper extremities supports that the enrollee can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of expandable controller and harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller and harness for a Group 3 power wheelchair.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on June 25, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you were told that the services
would be covered 100% due to COVID-19. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct 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 $120
copayment for emergency care.
You have been asked to pay the allowed amount of $81.74, which is less than the $120 copayment for
emergency care. Emergency care falls within the emergency 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 emergency care provided on June 25, 2020.