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

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 21, 2021, to July 23, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are unhappy with the nursing staff at the facility and for this reason you would like the copayment to be waived. 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 $300 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from July 21, 2021, to July 23, 2021. Therefore, you are responsible to pay a $300 copayment for days 1-2 (July 21, 2021, to July 22, 2021). The total amount you owe is: $600.
You have been asked to pay the total copayment amount of $600 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from July 21, 2021, to July 23, 2021.
We note your complaint that you are unhappy with the nursing staff at the facility. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says the rules for IRF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you were admitted for surgical repair of a femur fracture after a fall and was 
transferred to skilled nursing on November 13, 2021. Medical problems are stable.  
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While you have a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87070, 87075, 87205) provided on April 20, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-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 had network providers available who could have provided the 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 services. Therefore, we decided that the Plan does not have to pay for lab services (87070, 87075, 87205) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Aflibercept injections you received from February 5, 2021, to July 2, 2021.
You asked the Plan to waive the coinsurance for the Aflibercept injections. You say that you cannot afford this coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 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 drugs. You have been asked to pay 20% coinsurance for the Aflibercept injections. The Aflibercept injections fall within the Medicare Part B 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 Aflibercept injections you received from February 5, 2021, to July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a pain 
management specialist on February 3, 2021. 
 
You asked the Plan to waive the copayment for the pain management visit. You say that you do not feel as 
though you should have to pay this copayment because the doctor was not very professional. The Plan denied 
your request. The Plan says you were charged this copayment 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 specialist visits.  
 
You have been asked to pay a $30 copayment for the pain management visit. The pain management visit falls 
within the specialist visits benefit category.  
This copayment applies regardless of your satisfaction with the services received. 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 visit you had with a pain management specialist on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on April 28, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that your primary care physician said that you would not owe a copayment. 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 $0 copayment for laboratory services provided at a primary care providers office, specialist's office, a standalone lab or an urgent care and a $40 copayment when provided in an outpatient hospital setting. The record shows that you received laboratory services at an outpatient hospital facility on April 28, 2021. Therefore, you are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on April 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 Our physician reviewer found that you have a past medical history of diabetes, peripheral neuropathy, peripheral vascular disease, osteoarthritis, and paraplegia and currently living in a group home with functional decline and increasing weakness over last 2 months. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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.reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Keytruda injection you received on May 17, 2021.

You asked the Plan to waive the coinsurance for the Keytruda injection. You say that you believe you had hit your out-of-pocket expense for the year. The Plan denied your request. The Plan says you did not hit your out-of-pocket maximum until after this claim had processed. Before this claim, you still had $12.57 remaining on your out-of-pocket maximum, so that is what you are being charged in coinsurance for this injection.

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 drugs. 

You have been asked to pay 20% coinsurance for the Keytruda injection. The Plan provided us with a breakdown of your maximum-out-of-pocket. At the time this claim processed, you still had $12.57 remaining, which is why you were charged this amount in coinsurance for the drug you received. The Keytruda injection falls within the Medicare Part B 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 Keytruda injection you received on May 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin lesion destruction procedure you 
had at an outpatient hospital clinic on June 16, 2021. 
 
You asked the Plan to waive the copayment for the skin lesion destruction procedure. You say that this service 
should be treated like a doctor's office visit.  You said that you went to this facility to have some small spots 
removed.  You did not know that this procedure would cost this much. The Plan denied your request. The Plan 
says you are only being charged $435 for this procedure.  The Plan says that you were charged this copayment 
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 $435 
copayment for outpatient surgery and other medical services at hospital outpatient facilities.  
 
You have been asked to pay a $435 copayment for the skin lesion destruction procedure. Records show that 
these services were performed in an outpatient hospital clinic.  That is why the skin lesion destruction 
procedure falls within the outpatient surgery and other medical services at hospital outpatient facilities 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 skin lesion destruction procedure you had at 
an outpatient hospital clinic on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), adult dental 
prophylaxis (D1110), intraoral X-rays (D0210), and diagnostic casts (D0470) provided on June 15, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation, adult dental prophylaxis, intraoral X-rays, and 
diagnostic casts. You say that the Plan should be responsible for the dental services at issue due to their error of 
not recording your dental enrollment timely. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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. The Plan covers select dental 
services when provided by an in-network provider. 
 
The Plan's rules for coverage of a comprehensive oral evaluation, adult dental prophylaxis, and intraoral X-rays 
have not been met. Specifically, these services must be obtained from a network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, diagnostic casts are not among the services covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150), adult dental prophylaxis (D1110), intraoral X-rays (D0210), and diagnostic casts (D0470) 
provided on June 15, 2021.  
 
Your complaint about receiving erroneous or incomplete information about your network of providers from a 
representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance 
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs provided on February 11, 2021.
You asked the Plan to pay for the services provided. You say that there is no specific code billable. The Plan denied your request. The Plan says the billed service cannot be verified.
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 J7999 is compounded drug, not otherwise classified. We find that CPT code J7999 is not supported in the medical record. The medical records show that the enrollee received an intrathecal morphine pump refill. We looked at the file and the rules. There is a more comprehensive code available to describe the services provided.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the drugs provided on February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like reconsideration because the requested device is medically necessary. The Plan denied your request. The Plan says items that are used for a preventative service or function are excluded from coverage under the Medicare durable medical equipment benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 24, 2021, to June 3, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told that the stay would be fully covered. 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 $300 copayment for days 1-5 for inpatient hospital care.
You had an inpatient hospital stay from May 24, 2021, to June 3, 2021. Therefore, you are responsible to pay a $300 copayment for days 1-5 (May 24, 2021, to May 28, 2021). The total amount you owe is: $300 (copayment) x 5 (inpatient days) = $1,500. You have been asked to pay the total copayment amount of $1,500 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from May 24, 2021, to June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs you received during an outpatient procedure from June 21, 2021, to June 22, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were considered an outpatient for your knee surgery, but you did stay in the hospital overnight. You said that you were not able to bring your own self-administered drugs into the facility with you, so the hospital provided them. The Plan denied your request. The Plan says self-administered drugs are not covered under your medical benefits.
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 you received during an outpatient procedure from June 21, 2021, to June 22, 2021.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on June 8, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford this. The Plan 
denied your request. The Plan says the copayment applied was correct. 
 
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 for in-network advanced imaging services (not including x-rays).  
 
You have been asked to pay a $225 copayment for a CT scan. CT scans fall within the outpatient diagnostic 
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for a computed tomography (CT) scan provided on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on April 30, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you had no idea there would be a cost for this service. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for diagnostic radiology services. You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the diagnostic radiology 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 copayment for the computed tomography (CT) scan of the chest you had on April 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy visits. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers available. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for physical therapy visits.