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

We decided that the Plan does not have to waive the copayment fora diagnostic colonoscopy provided on October 17, 2019.You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you have had polyps removed before and you had no copayment.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 $250 copayment for outpatient surgery. You have been asked to pay a $250 copayment for a diagnostic colonoscopy. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed.A diagnostic colonoscopy 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 for a diagnostic colonoscopy provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on August 2, 2019.You asked the Plan to waive the copayment forthe office visit. You say that the procedure was declined. You say that you are refusing 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 $45 copayment for each Medicare-covered specialist visit.You have been asked to pay a $45 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 forthe office visit provided on August 2, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit, the electro-cardiogram, the SPECT test, or the stress test provided on July 30, 2019 and August 8, 2019.You asked the Plan to waive the copayments for the specialist office visit, the electrocardiogram, the SPECT test, and the stress test. You say that you do not feel that these fees are your financial responsibility. 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 $50 copayment for each covered specialist office visit, a $60 copayment each covered diagnostic procedure or test at a network doctor's office, and a $200 copayment for covered diagnostic radiology services in a provider's office or freestanding radiology center. You have been asked to pay a total of $392.29 for the specialist office visit, the electrocardiogram, the SPECT test, and the stress test. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.The electrocardiogram, the SPECT test, and the stress test fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visit, the electrocardiogram, the SPECT test, and the stress test provided on July 30, 2019 and August 8, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nujolix (belatacept) injections to be provided in the
home health setting.
You asked the Plan to pre-approve the Nujolix injections. You say that this infusion is necessary as she had a
recent kidney transplant. The Plan denied your request. The Plan says the use of this particular
immunosuppressive is not covered when administered in the home health setting. This must be provided in the
outpatient setting.
The Plan must follow Medicare rules. Medicare rules say that the immunosuppressive drug belatacept is not
proven to be safe when administered in the home and cannot be covered in that setting.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Nujolix injections have not been met. Therefore, we decided that the Plan does not have to preapprove
Nujolix (belatacept) injections to be provided in the home health setting.
Appeal type: Inpatient Hospital
Decision: Favorable

Wedecided that the Plan has to pay forthe acute inpatient hospital care provided June 30, 2019 to July 5, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that you are requesting the documentation be reviewed and approve based on medical necessity.The Plan denied your request. The Plan says that the services could have been provided at observation level of care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented with complaints of a headache and dizziness. Evaluation revealed clinically significant sinus bradycardia. A cardiology consultation was obtained. Telemetry monitoring revealed tachy-brady syndrome requiring additional medical interventions. At the time of inpatient admission,the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Inpatient admission was 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 acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided June 30, 2019 to July 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a partial laryngectomy provided on August 23, 2019.You asked the Plan to waive the copayment for a partial laryngectomy. You say that you feel that you should only owe a $35 copayment.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 $195 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a partial laryngectomy on August 23, 2019. A partial laryngectomy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $195 copayment. You have been asked to pay a $195 copayment for a partial laryngectomy. A partial laryngectomy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 partial laryngectomy provided on August 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says care can be received in another setting.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 there are no acute medical problems or evidence of the required medical complexity for IRF admission. Your therapy needs can be addressed in the SNF setting. IRF admission is not medically necessary based on your current functional status, and medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair electronic upgrades and bag hooks.You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), Expandable controller (E2377), and bag hooks (K0108). You say that the enrollee needs the upgraded electronics and bag hook The Plan denied your request. The Plan says there is not a medical need to control the power options through the joystick and bag hooks don not serve a medical purpose.The Plan must follow Medicare rules. Medicare rules state that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary.  Although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches.The denied accessories are upgrades to the standard equipment which are not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approve power wheelchair electronic upgrades and bag hooks.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the office visit. We decided that the Plan does not have to waive the copayment for the office visit.
You asked the Plan to waive the copayment for the office visit. You say that you paid $10 at the time of service. You say that you would not have gone if you knew you would be charged $70. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the copayment for the office visit.
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 records show that the provider is an out-of-network family nurse practitioner.
The Plan says that you must pay a $70 copayment for the office visit. Based on the Plan contract however, you cannot be asked to pay more than a $45 copayment for the office visit. Therefore, we decided that the Plan has to reduce the copayment for the office visit.
We also decided that the Plan does not have to waive the copayment for the office visit.
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 $45 copayment for services obtained from an out-of-network primary care provider. Therefore, we decided that the Plan does not have to waive the copayment for the office visit.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe urgent care visit provided on August 11, 2019.You asked the Plan to waive the copayment forthe urgent care visit. You say that your primary care office was busy that day. You say that you shouldn't be charged $65 for the visit.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 $65 copayment per visit for Medicare-covered urgently needed services.You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show that you were seen at an urgent care facility.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 urgent care visit provided on August 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia solution 60mg/ml for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or separate pharmacy benefit.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-approveProlia solution 60mg/ml for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis and addition to lower extremity, provided on June 26, 2019.
You asked the Plan to pay for the hip orthosis (L1686) and addition to lower extremity (L2624). You say that the orthosis and addition were medically necessary. The Plan denied your request. The Plan says there is no not in the medical record on or around the date of the order as to why the brace and addition was being ordered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no clinical records supporting medical necessity of the orthosis or addition. Based on this information, we decided that Medicare rules for coverage of the hip orthosis (L1686) and addition to lower extremity (L2624) have not been met. Therefore, we decided that the Plan does not have to pay for the hip orthosis and addition to lower extremity, provided on June 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skin glycation spectroscopy identified with code 0232T.You asked the Plan to pre-approve skin glycation spectroscopy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that services identified with code 0232T are not a covered benefit.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skin glycation spectroscopy have not been met.Therefore, we decided that the Plan does not have to pre-approve skin glycation spectroscopy identified with code 0232T.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the physician.
You asked the Plan to pre-approve the physician's services. You say that this physician is in the same building as your oncologist and you have a degenerative spine, which causes you pain and prohibits you from driving long distances. The Plan denied your request. The Plan says secondary network care may be allowed if your care cannot be performed by a doctor in our group. This service is available in our primary network of care givers
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the physician.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve Diovan HCT tab 160-12.5 for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe drug in question is not covered under the member's contract under any normal circumstances.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 Plandoes not haveto pre-approveDiovan HCT tab 160-12.5 for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. 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 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
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on
February 1, 2020 with encephalopathy secondary to a urinary tract infection (UTI). She was treated with
intravenous (IV) fluids and Ceftriaxone and the encephalopathy resolved. On February 14, 2020 she needed
minimal assist for gait over 150 feet with wheelchair propulsion. Her vital signs are stable and she has no
complaints. The UTI has resolved. She has no complex medical, nursing, or rehabilitation needs that require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from
further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Lab
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 June 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on June 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on September 19, 2019.You asked the Plan to waive the copayment for the ED visit. You say that no services were rendered. You say that the charges are out of line.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 $90 copayment for Medicare-covered emergency room visits.You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that the wound was cleaned and dressed, and a treatment plan was provided. 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 ED visit provided on September 19, 2019.