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

We decided that the Plan does not have to reduce the coinsurance for an ultralightweight wheelchair (K0005) and wheelchair accessories (K0038, E2622, E2611, E0986, E0978, E0973, E0971) provided on April 29, 2021, by an in-network provider.
You asked the Plan to reduce the coinsurance for the wheelchair and wheelchair accessories. You say that the bill is much higher than you expected and would like for your responsibility to be reduced The Plan denied your request. The Plan says the claim processed correctly. The Plan did not deny the services and says you are responsible for the coinsurance amount. The Plan also says the records indicate you did not call the Plan to verify DME 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 20% coinsurance for Durable Medical Equipment (DME) and Related Supplies. You have been asked to pay a cost-share of $1,269 for a wheelchair and wheelchair accessories, which fall within the Durable Medical Equipment (DME) and Related Supplies. The EOC states you must pay a 20% coinsurance for each Medicare-covered item. Ultralightweight wheelchair (K0005): Allowed Amount: $1848.76  20% = $369.75
Accessories K0038: Allowed Amount: $17.53  20% = $3.51
E2622: Allowed Amount: $364.00  20% = $72.80
E2611: Allowed Amount: $312.35  20% = $62.47
E0986: Allowed Amount: $3514.41  20% = $702.88 E0978: Allowed Amount: $30.85  20% = $6.17 E0973: Allowed Amount: $166.12  20% = $33.22
E0971: Allowed Amount: $95.02  20% = $19.00 Total: $369.75 + $3.51 + $72.80 + $62.47 + $702.88 + $6.17 + $33.22 + $19.00 = $1,269
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 reduce the coinsurance for an ultralightweight wheelchair (K0005) and wheelchair accessories (K0038, E2622, E2611, E0986, E0978, E0973, E0971) provided on April 29, 2021, by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve lumbar epidural. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not meet the imaging documentation requirements for coverage.
The Plan follows Medicare rules. Medicare rules state that lumbar epidural steroid injections may be covered under certain clinical criteria when imaging documentation requirements 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 pre-approve lumbar epidural. Our reviewer says that you do not meet the Medicare criteria for the requested lumbar epidural steroid injection. Our physician reviewer found there is no documentation of advanced imaging to fulfill this requirement. Therefore, this request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954), and recement of crown (D2920) provided on August 3, 2021.
You asked the Plan to pay for the dental services. You say that you would like to use your $300 for dental coverage towards these services. You say that you only get a cleaning once per year and you will pay for that. You say that a cap fell off and you needed it fixed. You also say that you do not have $300 to pay for that. The Plan denied your request. The Plan says the claim processed correctly as the services you received are not preventive 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 prefabricated post and core in addition to a crown and recement crown are not among those covered under this benefit as they are not preventive dental services. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to a crown (D2954), and recement of crown (D2920) provided on August 3, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on August 1, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were bitten by a cat and needed a rabies vaccine. You stated that none of the pharmacies near you had this vaccine so you had to go to the ER. You said that you called Medicare and were advised that this shot is covered 100%/ The Plan denied your request. The Plan says you are not being charged coinsurance for the vaccine. You are being charged a copayment for the ER visit. 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 $110 copayment for emergency room visits.
You have been asked to pay a $110 copayment for the ER visit. This copayment applies each time you go to
the ER, regardless of the reason for the visit. 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
emergency room (ER) visit you had on August 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the medical services. You say that you believe you should be reimbursed for the services you received while out of the country. The Plan denied your request. The Plan says there is no evidence the services were for an urgent/emergent situation.
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 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. Specifically, the medical documentation provided does not make it clear that the medical services were received on an urgent/emergency basis. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 4, 2021 by an out-of-network (OON) provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on June 30, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that because the services were ordered by a doctor, there should not be a copay. 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 $10 copayment for outpatient diagnostic tests other than those specifically named in the Evidence of Coverage. You have been asked to pay a $10 copayment for the ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound provided on June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric hospital services beginning November 22, 2021.
You asked the Plan to pre-approve inpatient psychiatric hospital services. The Plan denied your request. The Plan says continuation of inpatient psychiatric hospital services is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services.
Our reviewer says that continuation of inpatient psychiatric hospital services is not medically necessary. Our physician reviewer found based upon review the records provided, it was not expected you would improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You were compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have dangerousness to yourself or others but were compliant with your treatment. The health Plan's denial of continued inpatient psychiatric services is appropriate. You did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. It did appear that the records were supervised and evaluated by a physician. Based upon review, the records provided for the admission do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of November 22, 2021 forward as you were not shown to be a danger to yourself or others. You were not showing any delusions, auditory or visual hallucinations and were cooperative/compliant with treatment while not showing any threats the safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric hospital services beginning November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystourethroscopy procedure you had at an outpatient hospital facility on July 14, 2021.
You asked the Plan to waive the copayment for the cystourethroscopy procedure. You say that you have been getting these procedures since you were diagnosed. You said that until now, you have only paid a $25 copayment. You said that the doctor just used a room at the hospital, so the copayment for this service should be the same. 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 $325 copayment for outpatient hospital services.
You have been asked to pay a $325 copayment for the cystourethroscopy procedure. Because this service physically took place in an outpatient hospital facility, the outpatient hospital surgery copayment applies. You may have had this procedure in your doctor's office in the past, which resulted in a different copayment. 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 cystourethroscopy procedure you had at an outpatient hospital facility on July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from June 1, 2021, to June 11, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you think if you are admitted for an emergency this should be covered in full. 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 $275 copayment per day for days 1-5, and a $0 copayment after day 5 for inpatient hospital care.
Records show that you were in the hospital for 10 days. You were charged a $275 copayment per day for the first 5 days, for a total of $1375. YThis copayment applies regardless of the reason for the stay. 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 services you received from June 1, 2021, to June 11, 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 you fell and hurt your arm. You say that you have an irregular heartbeat and are still weak. You say that you need help and do not feel safe at home. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for rhabdomyolysis after a fall and has been discharged home. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness exam provided on May 19, 2021.
You asked the Plan to pay for the annual wellness exam. You say that you were unaware you had previously received these services. The Plan denied your request. The Plan says this benefit had been exhausted before this date of service.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness exam provided on
May 19, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy services provided on January 9, 2020.
You asked the Plan to pay for the arthroscopy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has been filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the arthroscopy services was not filed until July 19, 2021.. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the arthroscopy services provided on January 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services you received from March 24, 2021, to April 14, 2021.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that this should be treated as one admission. You said that you were in the hospital and transferred to the rehabilitation facility, so you should only have one copayment. 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 per admission for inpatient hospital services.
Records show that you had two separate admissions. You were in an acute inpatient hospital from
March 20, 2021, until March 24, 2021. You were discharged and then admitted to an inpatient rehabilitation hospital from March 24, 2021, to April 14, 2021. These are separate admissions at different facility types. 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 inpatient rehabilitation services you received from
March 24, 2021, to April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on July 21, 2021.
You asked the Plan to waive the copayment for the lab services. You say that these lab services were part of your annual wellness visit, so there should be no copayment. 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for the lab services. Your Evidence of Coverage says that there is separate cost sharing for lab services you receive as part of an annual physical or wellness visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab services you received on July 21, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sensipar coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 3, 2021, through June 29, 2021.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these claims require revisions before they can be paid.
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 90999 is unlisted dialysis procedure, inpatient or outpatient. The CPT Code Manual definition of code J0604 is cinacalcet, oral, 1 mg, (for end stage renal disease on dialysis). We find that CPT codes J0604 and 90999 is not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for Sensipar coded as J0604-AX and unlisted dialysis procedure coded as 90999 provided from January 3, 2021, through June 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous infusion services (96361) provided on June 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the intravenous infusion services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
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 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 intravenous infusion services (96361) provided on June 14, 2021 by an out-of-network (OON) provider