Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by an out of network provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for the services in question.
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 July 9, 2019 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on April 30, 2019.You asked the Plan to pay for the mental health services. You say that you have been seeing this provider since April of 2019 and were referred to them by the Plan. The Plan denied your request. The Plan says "the doctor",is a contracted provider with the Plan, but did not bill using the correct tax ID#.ThePlan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at your request, the file and the rules. Based on this information, we have determined that the Medicare rules for coverage of the mental healthservices have not been met. In this case, the requested provider is a network provider with the Plan, but billed with an incorrect tax ID#. The Plan has confirmed that you are not responsible for the payment and the office of "the doctor" should re-bill with the correct Tax ID#. Therefore, the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on April 30, 2019. Therefore, we decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on April 30, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for two root canals provided on June 13, 2019.You asked the Plan to pay for the root canals. You say that this service should be covered because it was related to an accident. The Plan denied your request. The Plan says this service is not reimbursable because it is not medical in nature.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 two root canals provided on June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe inpatient hospital stay provided from April 26, 2019 to April 29, 2019.You asked the Plan to waive the coinsurance forthe inpatient hospital stay. You say that you were told that the hospital took your insurance. 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 20% of the cost, after the deductible, per stay for out-of-network Medicare-covered hospital stays. You have been asked to pay $1,504.27 for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category.The record shows you had previously met your combined deductible and spent a total of $995.73 out-of-pocket. ($2,500 -$995.473 = $1,504.27). Therefore, you are only responsible for $1,504.27, which is less than the standard 20% coinsurance amount. 
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 forthe inpatient hospital stay provided from April 26, 2019 to April 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Acetaminophen, Cholecalciferol, Fentanyl, Fluticasone Propionate, Gabapentin, Magnesium Oxide, Melatonin, Omega-3 Fatty Acids-Fish Oil, Polyethylene Glycol, Tizanidine, Guaifenesin, Hydromorphone, Levothyroxine and Pantoprazole provided from August 9, 2019 through August 10, 2019.You asked the Plan to pay forthese drugs. You say that these drugs were given to you during your hospital stay and not self-given.The Plan denied your request. The Plan says that self-given drugs are not covered.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 pay forthe Acetaminophen, Cholecalciferol, Fentanyl, Fluticasone Propionate, Gabapentin, Magnesium Oxide, Melatonin, Omega-3 Fatty Acids-Fish Oil, Polyethylene Glycol, Tizanidine, Guaifenesin, Hydromorphone, Levothyroxine and Pantoprazole provided from August 9, 2019 through August 10, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Hospital Services provided January 10, 2019 to April 23, 2019.You asked the Plan to pay for the hospital services provided. You say that the services were emergent.The Plan denied your request. The Plan says incomplete records were provided, and those available were not translated as required by the plan contract. The services are not supported.The Plan must follow Medicare rules. Medicare rules say that the beneficiary must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The records provided did not provide the plan with sufficient information per the plan contract to determine whether payment is due. Based on this information, we decided that Medicare rules for coverage of the hospital services provided have not been met.Therefore, we decided that the Plan does not have to pay for Hospital Services provided January 10, 2019 to April 23, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe Spinal decompression, electroanalgesia therapy, and Class IV laser therapy provided by the provider from July 2, 2019 to July 9, 2019.You asked the Plan to pay forthese services. You say that your understanding was that you would be reimbursed for the services provided.The Plandenied your request. The Plan says that the services provided are not covered by Medicare, nor Independent Health.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. An invalid EOC has been submitted by the plan for review. We requested a corrected EOC, however the plan re-submitted a duplicate of the original coverage booklet issued.Therefore, we are unable to determine your coverage. We decided that the Plan has to pay forthe Spinal decompression,electroanalgesia therapy, and Class IV laser therapy provided from July 2, 2019 to July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist visits provided by "the providers" on August 19, 2019.You asked the Plan to waive the copayments forspecialist visits. You say that you should only owe one specialist copayment not two.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 toits 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 specialist visit. You had specialist visits provided by two different providers on August 19, 2019. Therefore, you are responsible to pay a $50 copayment per each visit. The total amount you owe is: $100.00.You have been asked to pay the total copayment amount of $100.00 for specialist visits. Specialist visits fall 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 copayments forspecialist visits provided by "the providers" on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by the out of
network provider.
You asked the Plan to pay for the practitioner services. You say that you received a letter from the Plan that advised no authorization was required for the services. The Plan denied your request. The
Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says
the services were not urgent or emergent in nature.
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 provider in this case is not a network provider with the Plan. 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 office visit provided by the out of network
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on June 20, 2019.You asked the Plan to pay for the office visit. You say that you went to the doctor due to an infection and this was not dental care. The Plan denied your request. The Plan says dental care for pain, cavities, abscess or structures directly supporting the teeth are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on June 20, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on January 23, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your
request. The Plan says that the denial of payment for these services is correct, because the records submitted do
not show that these tests meet Medicare coverage criteria.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
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 has not specified whether the ordering practitioner is
in-network or out-of-network with the Plan. The Plan has not submitted documentation of prior notice that
these tests would not be covered. These tests are not statutorily excluded from Medicare coverage. Without this
information, we cannot determine whether the lab order made by the provider constitutes plan-directed care,
which would justify coverage of this claim. Therefore, the Plan has not shown that its decision to deny payment
for these services is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to
pay for drug testing provided on January 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 16, 2019 by out of network provider.
You asked the Plan to pay for specialist services. 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.
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 August 16, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health services provided from July 31, 2019 to August 8, 2019. You asked the Plan to waive the copayment for the inpatient mental health services. You say that you should not be responsible for the copayment since it was not your decision to go to the hospital.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $225 copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for inpatient mental health care. You have been asked to pay $1,125 for the inpatient mental health services. $225 x 5 = $1,125. 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 inpatient mental health services provided from July 31, 2019 to August 8, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 23, 2019, to March 27, 2019.You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that the notes did not show a medical reason for inpatient admission.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 the 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 that the enrollee was a then 79-year-old female with dementia, atrialfibrillation, diabetes, seizure disorder, and hyperlipidemia who was brought by ambulance to the ED on March 23, 2019, for the evaluation of weakness and confusion. The evaluation revealed a UTI, metabolic encephalopathy and early pulmonary edema. She wastreated with IV fluids and IV antibiotics. She was admitted and underwent an MRI of the brain. Her condition stabilized and improved with medical therapy and she was transported back to the nursing facility on March 27, 2019. The record showed that at thetime of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 the acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 23, 2019, to March 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient post-stabilization care provided from June 5, 2019 at 2:47pm to June 6, 2019 at 11:12pm by"the hospital". You asked the Plan to pay forthe inpatient post-stabilization care. You say that the services were medically necessary.The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient post-stabilization care. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee appears to have been stable for transfer on June 5, 2019 at 2:46pm, when, having apparently been told he should be transferred, the enrollee refused to be transferred. By this time, the enrollee had received hemodialysis and been downgraded to a telemetry bed. He was noted to be hemodynamically stable and was tolerating oxygen via a nasal cannula. There is no documentation to support that the enrollee was still unstable. Any care provided after 2:46pm on June 5, 2019 is post-stabilization care and is not covered unless pre-authorized by the health plan.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 inpatient post-stabilization care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient post-stabilization care provided from June 5, 2019 at 2:47pm to June 6, 2019 at 11:12pm by "the hospital".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0637) provided to the enrollee on May 1, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation did not include a valid proof of delivery, or itemized billing and shipping invoice.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0637) provided to the enrollee on May 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided on August 5, 2019 to August 9, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you should not have to pay for this because it was not your fault.The Plan denied your request. The Plan says the correct copayment has been applied to the service that was provided.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/in-network. You have been asked to paya $150 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $600 ($150 x 4 days = $600). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 inpatient hospital stay provided on August 5, 2019 to August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe automatic external defibrillator provided on August 22, 2019.You asked the Plan to waive the coinsurance forthe automatic external defibrillator. You say that you should not have to pay this because you returned it after a couple of days.The Plan denied your request. The Plan says that your benefit 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 saysthat you must pay a 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the automatic external defibrillator. The automatic external defibrillator falls within the Durable medical equipment (DME) and related 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 forthe automatic external defibrillator provided on August 22, 2019.