Persius/hicric huggingface dataset:
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 enrollee is not at his baseline. The Plan denied
your request. The Plan says the enrollee does not need specialized nursing or an interdisciplinary team
approach to rehabilitation care.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for cardiac arrest and coronavirus. His medical
problems are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 waive the copayment for physician services and an outpatient surgery provided by participating providers on April 12, 2021, to April 22, 2021.
You asked the Plan to waive the copayment for physician services and an outpatient surgery. You say that you cannot afford these copayments. The Plan denied your request. The Plan says the correct copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services/in-network/specialist and a $325 copayment for outpatient surgery/in-network.
You have been asked to pay a $35 copayment for physician services and a $325 copayment for an outpatient
surgery. The total amount you are being asked to pay is $360 ($35 + $325 = $360). The correct copayments
have been applied to the services that were provided. Physician services fall within the physician/practitioner
services/in-network/specialist benefit category and an outpatient surgery falls within the outpatient surgery/innetwork
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 physician services and an
outpatient surgery provided by a participating provider and on April 12, 2021, to April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas machine or subcutaneous vitamin injections in treatment of chronic pain provided from January 28, 2021 to February 8, 2021.

You asked the Plan to pay for the Sanexas machine or subcutaneous vitamin injections in treatment of chronic pain. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Sanexas machine or subcutaneous vitamin injections in treatment of chronic pain. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic pain. There is no specific clinical rationale for the requested services. The enrollee does not have a diagnosis/condition that meets criteria for the services rendered. 

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 Sanexas machine or subcutaneous vitamin injections in treatment of chronic pain have not been met. Therefore, we decided that the Plan does not have to pay for the Sanexas machine or subcutaneous vitamin injections in treatment of chronic pain provided from January 28, 2021 to February 8, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation that exceeds a distance of 50 miles.

You asked the Plan to pre-approve routine transportation that exceeds a distance of 50 miles. You say that you have cancer and need to be able to continue your treatment. The Plan denied your request. The Plan says rules for routine transportation have not been met.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, the requested transportation exceeds a distance of 50 miles. Therefore, we decided that the Plan does not have to pre-approve routine transportation that exceeds a distance of 50 miles.
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 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower 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: 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 enrollee is unable to ambulate independently with a walker. The Plan denied your request. The Plan says there is no clinical advantage of the IRF over the acute hospital.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for bilateral foot drop, had a lumbar laminectomy and resection of synovial cyst. Her medical problems are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab services you received from an out-of-network provider on February 4, 2021.

You asked the Plan to waive the coinsurance for the lab services. You say that the pain clinic said they were not going to use your insurance card. You do not know what this bill is for. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You received drug testing lab services from this out-of-network provider.

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 50% of the Medicare-allowed amount for out-of-network lab services. 

You have been asked to pay 50% of the Medicare-allowed amount for the lab services. 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 lab services you received from an out-of-network provider on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic visit received on June 21, 2021.

You asked the Plan to pay for the chiropractic visit. You say that you have made good progress with this provider. The Plan denied your request. The Plan says you exceeded your chiropractic benefit limit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The documentation shows that the Plan covers six routine chiropractic visits every year. Review of the file shows that you used your six visits on June 7, 2021, June 10, 2021, June 11, 2021, June 14, 2021, June 16, 2021, and June 18, 2021. This means you have met your Plan limit for chiropractic services before your visit on June 21, 2021. Therefore, we decided that the Plan does not have to pay for the chiropractic visit received on June 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the emergency room (ER) visit you had on April 12, 2021.
You asked the Plan to reduce the copayment for the ER visit. You say that you should only have to pay the $10 copayment that applies to urgent care. You said that the closest urgent care center to you doesn't accept your insurance. You said that the contracted urgent care centers are 11.65 and 15.68 miles away, and you believe that is unacceptable. You said that is why you had to go to the ER instead. 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 $70 copayment for emergency room visits. You have been asked to pay a $70 copayment for the ER visit. This copayment applies regardless of the reason for going to the ER. 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 copayment for the emergency room (ER) visit you had on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of muscle and/or fascia (11043), the debridement of subcutaneous tissue (11042), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on April 19, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The 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 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 debridement of muscle and/or fascia (11043), the debridement of subcutaneous tissue (11042), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab services you received from an out-of-network provider on March 4, 2021.

You asked the Plan to waive the coinsurance for the lab services. You say that the pain clinic said they were not going to use your insurance card. You do not know what this bill is for. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You received drug testing lab services from this out-of-network provider.

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 50% of the Medicare-allowed amount for out-of-network lab services. 

You have been asked to pay 50% of the Medicare-allowed amount for the lab services. 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 lab services you received from an out-of-network provider on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient cardiac ablation procedure you had on May 28, 2021.

You asked the Plan to waive the coinsurance for the outpatient cardiac ablation procedure. You say that you were told by your cardiologist that you would be staying overnight, so you thought you would only have to pay the inpatient copayment. The Plan denied your request. The Plan says you were charged this coinsurance correctly because you were not formally admitted to the hospital as an inpatient.

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 outpatient surgery and services at an outpatient hospital facility. In addition, your contract says if you are having surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or outpatient.

Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an outpatient. 

You have been asked to pay 20% coinsurance for the outpatient cardiac ablation procedure. The medical records confirm that you were not admitted as an inpatient. Your contract explicitly states that you may be considered an outpatient even if you stay overnight. 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 outpatient cardiac ablation procedure you had on May 28, 2021.
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 clinical information provided supports the enrollee's need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services needed could be provided in another setting.

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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. There is no evidence that the enrollee requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve pneumatic compression device. You say that you need this device. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this provider is out-of-network with the Plan and this equipment can be supplied by an in-network 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 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 a pneumatic compression device to be provided by an out-of-network (OON) provider.
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 enrollee is independent enough to benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee does not require an intensive, multidisciplinary approach to daily therapy.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for non-surgical management of a subarachnoid hemorrhage and thoracic compression fractures after a fall. Her medical problems are stable. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to fully pay for the eye exam provided on January 19, 2021.

You asked the Plan to fully pay for the eye exam. You say that the refraction should be paid as it is necessary to have the correct strength in your lens. You say that you are appealing the refraction fee of $30 and the copayment charge of $50. The Plan denied your request. The Plan says the copayment applied correctly to the eye exam and the claim reprocessed to pay for the refraction.

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 $50 copayment for Medicare covered vision services at an in-network specialist's office.

You have been asked to pay a $50 copayment for the eye exam. The eye exam falls within the "Vision 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 fully pay for the eye exam provided on January 19, 2021.