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

We decided that the Plan does not have to waive the copayment for SNF care from November 1, 2019 through November 29, 2019. You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). According to your benefits, there is a $0 copayment each day for days 1 to 20 of the benefit period and $160 copayment for each day for days 21 to 48 of the benefit period for SNF care the member receives. You received 34 days of SNF care from October 26, 2019 to November 29, 2019. Day 1 is the first day of the benefit period and when you were admitted into the facility. October 26, 2019 is day 1 of the benefit period. The SNF days do not restart every month and continue until you have not been an inpatient for 60 days. You are responsible for the $160 copayment each day for days 21 to 34 of the benefit period. You were discharged on November 29, 2019 which is not counted towards the SNF days and has no copayments. You are responsible for paying your share of the cost when you get a covered service. You received SNF care from November 01, 2019 to November 29,2019; therefore, you are responsible for the copayment of $2,240. 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 SNF care from November 1, 2019 through November 29, 2019.
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-approve the 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 you are currently undergoing treatment at an acute care hospital (ACH) following an abdominal gunshot wound. You underwent surgery and transiently received IV nutrition. You are now tolerating oral nutrition and are not intubated/ventilated. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services rendered to the enrollee on February 18, 2019.
You asked the Plan to waive the copayment for these services. You say that the provider is associated with your primary care physician (PCP). The Plan denied your request. The Plan says the copayment was applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for Medicare-covered specialist services. Review of the file shows that you received office visit services on February 18, 2019. You have been asked to pay a $30 copayment for these services. These services fall within the Medicare-covered specialist 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. The Plan confirmed that you did not have a PCP assigned to you on the date of service at issue. Therefore, we decided that the Plan does not have to waive the copayment for the services rendered to the enrollee on February 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 4, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that the colonoscopy should be considered diagnostic, not preventative, and you should not be responsible for 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a diagnostic colonoscopy on December 4, 2019 due to rectal bleeding. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services 
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 not billed correctly.
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that the laboratory was not properly CLIA certified. 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 laboratory services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on October 25, 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 the physician's services provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services
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 not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The file shows that the provider submitted a claim for procedure code 00910 with POS code 23 for emergency room. The enrollee was under inpatient status on the date of service; therefore, the POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for the anesthesia services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on November 22, 2019.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you were covered for the injection during your emergency room visit. You say that you disagree with the charges. 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $215.35, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,076.75 (20% x $1,076.75 = $215.35). The denosumab injection falls within the "Medicare Part B prescription drugs" 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 denosumab injection provided on November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from November 21, 2019 to November 22, 2019.
You asked the Plan to pay for the self-administered drugs. You say that the hospital staff would not allow you to take your own medicines. The Plan denied your request. The Plan says the denied drugs are self-administer drugs not covered by Part B.
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 for the self-administered drugs provided from November 21, 2019 to November 22, 2019.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was readmitted after recent discharge from IRF. The enrollee presented to the emergency department due to weakness resulting in inability to perform activities of daily living and ambulation. The enrollee was not able to complete transfers from bed to chair. Recently completed treatment with cefepime and Vancomycin for peritonitis with MSAA She is on peritoneal dialysis. As per a 4/13/2020 report, the provider indicates there are no overnight events, and the enrollee is without fever and hemodynamically stable. The enrollee had a prior IRF stint and no real benefit was derived. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, skin/wound care, dialysis care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF level of care.
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 sedation services (99152) provided on July 6, 2019.
You asked the Plan to pay for sedation services. You say that these services are documented in the records. The Plan denied your request. The Plan says the documentation does not support this code.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted records do not demonstrate the presence of an independent trained observer to assist in the monitoring of the patient. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided on July 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 4, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you could've been transported in a private car. The Plan denied your request. The Plan says that cost sharing is a contractual obligation of the plan and cannot be waived.
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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 the ambulance transport provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit solution 3,000 unit/ml for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medicaly necessary. The Plan denied your request. The Plan says the prescription from the doctor does not meet the established pre-authorization criteria.
The Plan  must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that this drug is medically necessary for the enrollee, as the enrollee's hemoglobin level is 11.5 grams/dl. The documentation does not support that this drug would be safe and effective for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit solution 3,000 unit/ml for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on November 26, 2019 and November 27, 2019.
You asked the Plan to waive the copayment for the office visits. You say that the pessary was not able to be inserted and you had to return. You say that this was not your fault. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment per in-network specialist office visit. You have been asked to pay a $40 copayment for each office visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). The office 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 copayment for the office visits provided on November 26, 2019 and November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided from July 18, 2019 through September 18, 2019 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file show that you received an automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided from July 18, 2019 through September 18, 2019 by an in-network provider. You are asked to pay 20% coinsurance per date of service for the DME. 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 automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) provided from July 18, 2019 through September 18, 2019 by an in-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you woke up to a pool of blood on your pillow. You put a paper wad in your nose however the bleeding would not stop. You say that you live alone and have no available ride to the hospital so you called 911. When the responders arrived they gave you a new bandage to place in your nose and evaluated you. You say that the bleeding had stopped and you did not use the new wad. You stated that you were told to wait for thirty minutes and if the bleeding started again to call. You say you did not call back and you were never in the ambulance when they had come. You believe the services should be covered because you were bleeding seriously and needed help. You say that calling 911 seemed like the only solution and you thought it would be covered. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 15, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing 
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are
non-covered, VKORC1 and MTHFR testing are non-covered, and F2 and F5 testing is covered only for
pregnant women.
The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code.
Furthermore, this testing is not covered by Medicare. The file shows that the enrollee also received MTHFR,
VKORC1, F2, and F5 testing. These genetic tests are not covered. Therefore, we decided that the Plan does not
have to pay for the genetic testing
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an infusion provided on November 26, 2019.
You asked the Plan to waive the copayment for an infusion. You say that you disagree with how the claims were processed. 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 $250 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay $213.17, which is less than the $250 copayment for an infusion. An infusion falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an infusion provided on November 26, 2019.