Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total of seven home health physical therapy visits (three have been approved).
You asked the Plan to pre-approve the home health services. You say that you continue to be in excruciating pain and feel that more in-home therapy is needed. The Plan denied your request. The Plan says the approved three visits will be sufficient to complete self-care goals and transition to outpatient therapy.
The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be 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 a total of seven home health physical therapy visits (three have been approved). Our reviewer says that the documentation does not support that the enrollee remains homebound at this time or that ongoing physical therapy in the home is reasonable and necessary. Our physician reviewer found the enrollee was diagnosed with left shoulder girdle fracture with routine healing and a hemiarthroplasty on 10/30/19. The patient started home health PT on 12/13/19. The notes states that by 1/29/2020, the patient was independent in a home exercise program and by 1/31/2020 the patient was independent for in home ambulation, could manage a curb and flight of steps into the second floor with a rail and is able to ambulate all steps at entry of the home including able to take the trash out of the home. The physical therapy home health record of 1/31/2020 states that the patient no longer meets homebound criteria and can transition to outpatient therapy. Plan approved 3 of the 7 visits requested. At issue are 4 additional Home Health PT visits. Medicare coverage criteria are not met. The documentation does not support that the patient is homebound or requires ongoing skilled therapy services to effectively provide treatment, care, and/or services which are medically necessary for the patient.
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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve a total of seven home health physical therapy visits (three have been approved).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on December 12, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that this was an emergency transport soyou should not have to pay.The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles andcoinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each ground ambulance transport. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the ground ambulance transport 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 thatthe Plan does not have to waive the copayment forthe ambulance transport provided on December 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on June 18, 2019.
You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan says that the cost sharing applies to each one-way trip.
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 $300 copay for Medicare covered ground transportation services. You have been asked to pay a $300 copay for the ambulance transport. The ambulance transport falls within the Medicare covered ground transportation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the ambulance transport provided on June 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the MRI's provided on September 16, 2019 and September 24, 2019.
You asked the Plan to waive the cost share for the MRI's. You say that you were not informed the MRI's were out-of-network. You say that you were not informed of the excessive fees being charged. The Plan denied your request. The Plan says the cost share applied correctly.
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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Your contract with the Plan says that after you pay your $1,000 deductible, you pay 30% coinsurance for out-of-network diagnostic radiology. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network diagnostic radiology. This cost sharing is a contractual obligation that had not been met at the time the MRI was received on September 16, 2019. Therefore, the remaining amount of $442.90 has been applied to the deductible.
Since your $1,000 deductible has been met you have also been asked to pay 30% coinsurance for the MRI provided on September 16, 2019 and September 24, 2019.


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 for the MRI's provided on September 16, 2019 and September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from September 20, 2019 to October 19, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from September 20, 2019 to October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 24, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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
physician's services. 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 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on November 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 November 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the abdomen and pelvis (74176) provided September 28, 2019.
You asked the Plan to pay for the CT scan. You say that services were medically necessary and billed correctly. The Plan denied your request. The Plan says the service at issue shares a column One / Column Two relationship with another service 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, we have confirmed that code 74176 has a Column One / Column Two relationship with code 74177 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the abdomen and pelvis (74176) provided September 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stay and the observation stay provided from June 7, 2019 to October 31, 2019.
You asked the Plan to waive the copayments for the inpatient hospital stay and the observation stay. You say that you are appealing the copayments. You say you were not an outpatient on October 30, 2019 to October 31, 2019. 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 $290 copayment per day for days 1-6 per admission and a $400 copayment per stay for outpatient observation stay. You have been asked to pay a $290 copayment for the inpatient hospital stay and a $400 copayment for the observation stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The observation stay falls within the "Outpatient hospital services" benefit category. The record shows you were received observation services on October 30, 2019 to October 31, 2019.
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 inpatient hospital stay or the observation stay provided from June 7, 2019 to October 31, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the coinsurance for surgery services provided on October 15, 2019.
You asked the Plan to waive the coinsurance for surgery services. You say that the operating room services
were not covered. You say that you aren't responsible for these charges. The Plan denied your request. The Plan
says that the coinsurance applied correctly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not submit the correct explanation of benefits. This means that the
Plan the plan has not shown that the coinsurance amount you are being asked to pay is correct or justified by
the health plan contract. Therefore, we decided that the Plan has to waive the coinsurance for surgery services
provided on October 15, 2019
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for 30 units of alginate or other fiber gelling dressing covers (A6196) and 30 non-impregnated gauze dressings (A6219) provided by September 23, 2019.
You asked the Plan to pay for 30 units of alginate or other fiber gelling dressing covers and 30 non-impregnated gauze dressings. You say that these items meet Medicare coverage criteria. The Plan denied your request. The Plan says that these items are not covered.
The Plan follows Medicare rules. Medicare rules say that surgical dressings are covered when the above listed criteria are met. 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 30 units of alginate or other fiber gelling dressing covers and 30 non-impregnated gauze dressings. Our reviewer says that the items at issue met Medicare coverage criteria. Our physician reviewer found an alginate dressing is covered for the enrollee in this case, as she has a moderately to highly exudative full thickness wound. The records show that the appropriate amount of alginate dressing and gauze were used per Medicare guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 30 units of alginate or other fiber gelling dressing covers and 30 non-impregnated gauze dressings have been met. Therefore, we decided that the Plan has to pay for 30 units of alginate or other fiber gelling dressing covers (A6196) and 30 non-impregnated gauze dressings (A6219) provided by September 23, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, and
bitewings provided on December 17, 2019.
You asked the Plan to pay for the bitewings, prophylaxis, and comprehensive oral evaluation. You say that you
found a better dentist to provide these services and believe they should be paid for because they were only
provided 14 days before the new calendar year. The Plan denied your request. The Plan says the benefit
maximums for these services for the time period or occurrence had been reached.
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, you are limited to one oral
examination, one routine cleaning, and one set of bitewing x-rays per year. The record shows that you received
an oral evaluation, prophylaxis, and bitewings on April 24, 2019 and your oral evaluation, routine cleaning, and
bitewings benefits were then exhausted. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation, prophylaxis, and bitewings provided on December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray of the knee (73562) provided October 8, 2019.
You asked the Plan to waive the copayment for the X-ray. You say that you already received another x-ray the same day and should not have to pay a copayment. 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 $75 copayment for Basic Radiology Services. You have been asked to pay a $52.86 copayment for the X-ray. The X-ray falls within the Basic Radiology Services benefit category. The allowable amount is less than the $75 copayment stipulated in the contract. The allowable amount of $52.86 has been charged instead. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray of the knee (73562) provided October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on December 3, 2019.
You asked the Plan to pay for the complete series of intraoral x-rays. You say that you looked at the Plan's list online of in-network providers and this provider was listed as an approved dentist. The Plan denied your request. The Plan says intraoral radiographic imaging is not a covered service 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 complete series of intraoral x-rays (D0210) provided on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care from October 28, 2019 through November 03,
2019. You asked the Plan to pay for 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 Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pay for inpatient hospital care from October 28, 2019 through November 03, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for post-stabilization care provided to the enrollee from September 1, 2019 through September 3, 2019. You asked the Plan to pay for the post-stabilization care. You say that the patient came in on a Sunday and the Monday was labor day. You state you called and requested an authorization the next business day. The Plan denied your request. The Plan says that this case fails to meet criteria due to lack of evidence in the documentation to support the need for inpatient status. The Plan states there is no clinical documentation available for review that supports and needs such as hemodynamic instability to require an inpatient level of care. The Plan states the care possibly could have been provided at a lower level of care. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. Therefore, we decided that the Plan has to pay for post-stabilization care provided to the enrollee from September 1, 2019 through September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe biopsy services you received on October 17, 2019.You asked the Plan to waive the copay forthe services provided. You say that you have the same visit every 6 months with only a $30 copay.The Plan denied your request. The Plan says the copay was applied based on your plan benefits.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 $160 copay for outpatient surgery. You have been asked to pay a $160 copay for the services provided. The services fall 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 copay forthe biopsy services you received on October 17, 2019.