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

We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on March 2,
2020.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you should not have to pay
for these since you haven't had to previously. The Plan denied your request. The Plan says that you have a 20%
coinsurance.
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 prosthetic devices and medical supplies.
You have been asked to pay a 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the
prosthetic devices and medical 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 coinsurance
for the ostomy supplies provided on March 2, 2020.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for a duplex scan. We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging. You asked the Plan to reduce the cost-sharing charges for a duplex scan. You say that you cannot afford the charges and are new to the policy. The Plan says that the claims were processed correctly and you are being charged the correct amount. We decided that the Plan has to reduce the cost-sharing charges for a duplex scan from $190 to $110. The health plan contract says that enrollees must pay a $110 copayment for basic imaging provided in an outpatient hospital facility. A duplex scan is considered basic imaging. Therefore, you cannot be asked to pay more than a $110 copayment. We decided that the Plan has to reduce the cost-sharing charges for a duplex scan from $190 to $110. We also decided that the Plan does not have to waive the copayment for myocardial perfusion imaging. 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 $190 copayment for advanced imaging. Therefore, we decided that the Plan does not have to waive the copayment for myocardial perfusion imaging.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on December 12, 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 codes 27369 and 77002 are not supported.
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 27369 is injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography. The definition of code 77002 is fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). We find that CPT codes 27369 and 77002 are not supported in the medical record. Specifically, there is no documentation of an injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography to support code 27369. Given that the primary procedure code 27369 is not supported, add-on code 77002 is also not supported. 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 services rendered on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on September 15, 2019 by an out of network (OON) provider.You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 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 an outpatient visit provided on September 15, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab tests provided by a participating facility on January 29, 2020.
You asked the Plan to waive the copayment for lab tests. You say that you were told to get this lab work done. You say that no one told you that you would have a 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 $10 copayment for outpatient diagnostic tests/lab tests. You have been asked to pay a $10 copayment for lab tests. The correct copayment has been applied to the tests that were provide. Lab tests fall within the outpatient diagnostic tests/lab tests 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 lab tests provided by a participating facility on January 29, 2020.
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-approvethe 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe chemotherapy injections and the x-ray from January 2, 2020 to January 30, 2020.You asked the Plan to waive the cost share forthe chemotherapy injections and the x-ray. You say that you cannot afford to pay these bills.The Plandenied 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 20% coinsurance for Medicare Part B prescription drugs and a $40 copayment for each basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a total of $1,759.43 for the chemotherapy injections and the x-ray. The chemotherapy injections fall within the "Medicare Part B prescription drugs" benefit category. The 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 cost share forthe chemotherapy injections and the x-ray provided from January 2, 2020 to January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit and laboratory test provided on January 13, 2020 and home health supervision on January 22, 2020.You asked the Plan to waive the coinsurance for the office visit, laboratory test and home health supervision. You say that your doctor is out-of-network but you shouldn't be charged for a follow up visit.The Plan denied your request. The Plan says the coinsurance 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 30% for each Medicare-covered visit with an out-of-network PCP or specialist and 30% per day, per provider, for Medicare-covered lab services from an out-of-network provider. You have been asked to pay a total of $62.61 for the office visit, laboratory test and home health supervision. The office visit and home health supervision fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 office visit and laboratory test provided on January 13, 2020 and home health supervision on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care services provided from December 11, 2019 to
February 28, 2020.
You asked the Plan to pay for personal care services. You say that these services were needed because the
enrollee did not receive other care or instructions when discharged from surgery. The Plan denied your request.
The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered.
We looked at the file and Medicare rules. The services at issue are custodial in nature. Based on this
information, we decided that Medicare rules for coverage of personal care services have not been met.
Therefore, we decided that the Plan does not have to pay for personal care services provided from December
11, 2019 to February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 1, 2019 by an out of network (OON) provider.
You asked the Plan to pay for X-Ray examinations. You say that you are appealing with records to support these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 1, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse routine transportation provided on November 18, 2019.
You asked the Plan to reimburse routine transportation. You say that you were not given a choice of other transportation to get to your physical therapy sessions. The Plan denied your request. The Plan says routine transportation is not covered under any condition.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation have not been met. You were not transported by an ambulance and no other means of transportation are reimbursable. Your EOC states, Routine Transportation- Not covered under any circumstances. Therefore, we decided that the Plan does not have to reimburse routine transportation provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 6, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 25, 2018 through December 27, 2018.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.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 review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.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 thePlan has to pay for the acute inpatient hospital care provided from December 25, 2018 through December 27, 2018.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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 2, 2019 to December 26, 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 the claim was billed with the incorrect type of bill.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required 032x TOB code. 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 home health services rendered from December 2, 2019 to December 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room services provided
November 30, 2019.
You asked the Plan to waive the copayment for the Emergency Room services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment for Emergency Care.
You have been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room
services fall 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 Room services provided November 30, 2019.