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

We decided that the Plan does not have to adjust the copayment for the inpatient hospital care provided by the hospital, from September 4, 2019 to September 9, 2019.You asked the Plan to adjust the copayment.You say that you are requesting an adjustment of your copayment liability as you were charged for two additional days for your hospital stay.The Plan denied your request. The Plan says the correct copayment has been applied for your inpatient hospital stay.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 $360 copayment per day, for days 1-5 for inpatient hospital care. You have been asked to pay a $1,440 copayment ($360 x 4days)for inpatient hospital care. 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 adjust the copayment for the inpatient hospital care provided September 4, 2019 to September 9, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient services provided from August 16, 2019 to August 31, 2019.You asked the Plan to pay for the SNF services. You say that the codes are billable for hospice services.The Plan denied your request. The Plan says the Medicare hospice benefit, throughfee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe inpatient services provided from August 16, 2019 to August 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device (22869).You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device. You say that the services are medically 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. 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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of an interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device (22869).
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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not require IRF care.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 that you are medically stable with no evidence of need for supervision by a physical medicine and rehabilitation physician or needs acute rehab nursing care. You may benefit from further therapy but do not require an intensive therapy program. 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652).You asked the Plan to pre-approvea pneumatic compression device. You say that you are appealing the denial of coverage for the pneumatic compression device.The Plandenied your request. The Plan says the records do not show that the enrollee has had a failed four week trial of a basic device of either E0650 or E0651.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 27, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on September 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you need to regain strength and endurance to return home safely. The Plan denied your request. The Plan says you do not have a change in function to require daily skilled services, or skilled nursing needs.
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 SNF services. Our physician reviewer found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at standby assist to contact guard assist with functional mobility. You required varying assist for activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered to the enrollee on July 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 01992 is not separately payable.
The Plan must follow Medicare rules. The rules say that if an epidural injection is not utilized for operative anesthesia but is utilized for postoperative pain management, modifier 59 may be reported to indicate that the epidural injection was performed for postoperative pain management rather than intraoperative pain management. We looked at the file and Medicare rules. The file shows that the provider submitted a claim for an epidural steroid injection with anesthesia code 01992. Code 01992 was not billed with the required -59 modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered to the enrollee on July 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aids (V5260) provided on October 28, 2019.You asked the Plan to issue reimbursementfor the hearing aids. You say that you are requesting a reconsideration of the Plan's denial as you believedthis provider was in-network with the health plan.The Plan denied your request. The Plan says the hearing aids were provided by an out of network provider without 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 issue reimbursement care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the hearing aidsat issue in this appeal. The Plan did not pre-approve the hearing aids. We found no exception that would require the Plan to issue reimbursement for these hearing aids.Therefore, we decided that the Plan does not have to issue reimbursementfor the hearing aids (V5260) provided by the out of network provider on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 3, 2019.You asked the Plan to pay for the dental service. You say that the provider knew that you had already received the x-rays and they still continued with them on the date of service. You say that you should not have to pay for the provider's mistake.The Plan denied your request. The Plan says the frequency limit for dental x-rays has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and panoramic x-rays are a covered service, the frequency limit has been exceeded. The record shows the Plan previously paid for a dental x-ray on May 7, 2019.Therefore, we decided that the Plan does not have to pay fo rthe panoramic x-ray (D0330) provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee.
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says there has not been 3 months of conservative therapy.
The Plan follows Medicare rules. Medicare rules say that hyaluronate polymers are only covered under certain medical indications. 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 Synvisc-One. Our physician reviewer found that the enrollee has bilateral osteoarthritis of her knees. She is diabetic, but is poorly compliant with her medications and measuring her blood glucose levels. She is taking topical diclofenac and hydrocodone/ acetaminophen for pain. There is no documentation of prior intra-articular steroid trial or of physical therapy. The enrollee has not had an adequate trial of conservative therapy. Therefore, the request is considered not medically reasonable or 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc-One injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 5, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 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 physician's services provided on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 9, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on May 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need incontinence supplies. 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 incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe compression stockings identified with code A6530 that were issued on September 16, 2019.You asked the Plan to pay forthe compression stockings. You say that you were told that this would be covered.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncoveredbecause they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay forthe compression stockings identified with code A6530 that were issued on September 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance foran inpatient hospital stay from October 4, 2019 to October 5, 2019.You asked the Plan to waive the deductible and coinsurance foran inpatient hospital stay. You say that you were admitted against your will and disagree with the charges.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. Your contract with the Plan says that there is a $250 deductible for inpatient hospital care. Your contract with the Plan also clearly says that after the $250 deductible has been met, enrollees must pay 10% coinsurance for inpatient hospital care.You had an inpatient hospital stay from October 4, 2019 to October 5, 2019. The record shows that you had paid $0 toward the $250 deductible prior to receiving services. Therefore, you are responsible to pay the $250 deductible. Now that the deductible has been met you are also responsible to pay 10% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. $8,490.18 (allowed amount) -$250 (deductible) = $8,240.18 and 10% of that is $824.03. The total amount you owe is: $250 + $824.03 = $1,074.03. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for inpatient hospital care. The Plan also followed Medicare rules by clearlydisclosing in the contract that after the $250 deductible has been met, enrollees must pay 10% coinsurance for inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time an inpatient hospital stay was receivedon October 4, 2019 to October 5, 2019.Therefore, we decided that the Plan does not have to waive the deductible and coinsurance foran inpatient hospital stay from October 4, 2019 to October 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on September 17, 2019.You asked the Plan to waive the copayment foran X-ray. You say that you already paid the $50 copayment and disagree with the additional charges.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 $50 copayment basic radiological services provided in an outpatient hospital. You have been asked to pay a $50 copayment for an X-ray. An X-ray 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 foran X-ray provided on September 17,2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegenetic testing.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that The rules say that testing of the SLC24A4, POLG, C10ORF2, and OPA1 genes is automatically denied as not medically necessary.We looked at the file and Medicare rules. The services at issue are testing of the SLC24A4, POLG, C10ORF2, and OPA1 genes.Therefore, we decided that the Plandoes not have to pre-approvegenetic testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on April 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on May 14, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed.Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on May 14, 2019.