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

We decided that the Plan does not have to waive the copayment for ambulance services you received on
October 5, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that your doctor gave you
Tylenol with codeine in it which is harmful to you. You said that you had to take an ambulance because your
heart was racing after taking the medication. You do not feel as though you should have to pay this
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 $290
copayment per trip for ambulance services.
You have been asked to pay a $290 copayment per trip for the ambulance services. This copayment applies
regardless of the reason for the transport. 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 ambulance
services you received on October 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on August 30, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you feel as though you should only be responsible for 20% of the amount. 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 for ambulance services.   You have been asked to pay a $275 copayment for the ambulance services. When you join a Medicare Advantage plan, your cost sharing is based on what is in your Evidence of Coverage, not on the Original Medicare coinsurance rate. 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 ambulance services you received on August 30, 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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. he enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.  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 the enrollee appears to be stable and improving and requires only short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to an LTACH is not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel syndrome consultation and care to be
provided by an out-of-network provider.
You asked the Plan to pre-approve carpal tunnel syndrome consultation and care. You say that the requested
care is a necessity for you. The Plan denied your request. The Plan says rules for coverage for out-of-network
care have not been met.
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 carpal tunnel syndrome consultation and care to be provided by an
out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on September 16, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you could have been transferred by other means but you weren't given a choice. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($278.41) is less than your copayment obligation, you are responsible for the full allowed 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 $325 copayment for ambulance services.   You have been asked to pay a $325 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.
You asked the Plan to pay for IRF care. You say that you need inpatient rehabilitation to recover fully. The
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The services you need
can safely be provided in a lower level of 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 pay for 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 the complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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 pay for 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 a back injection provided on June 3, 2021.

You asked the Plan to waive the copayment for the injection. You say that you were not informed of the high copayment. 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 $450 copayment per visit for outpatient procedures.

You have been asked to pay a $450 copayment for the injection. Please note that injections are considered surgical procedures. The injection 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 back injection provided on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services you received from August 3, 2021, to August 16, 2021.

You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you believe this stay was an extension of your first hospitalization, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were in an inpatient acute hospitalization from July 25, 2021, to August 3, 2021. On that date, you were discharged from the acute inpatient admission, and then admitted to an inpatient rehabilitation hospital. You were in the inpatient rehabilitation hospital from August 3, 2021, to August 16, 2021.

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 for inpatient hospital care. This copayment applies each time you are admitted.

You have been asked to pay a $275 copayment per day for days 1-5 for the inpatient rehabilitation services. Because you were discharged from one type of facility (acute inpatient hospital) and transferred and admitted to a different type of facility (inpatient rehabilitation hospital), these are considered separate admissions for which separate copayments apply. 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 rehabilitation services you received from August 3, 2021, to August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Fluorescence in situ Hybridization (FISH) test (code
88120).
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says this testing was ordered as a screening.
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in
the Medicare rules section, are not covered.
The records show Fluorescence in situ Hybridization (FISH) testing was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for a Fluorescence in situ Hybridization (FISH) test (code 88120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the seat lift mechanism, electric, any type
(E0627) and the lift chair (A9270) purchased from the out-of-network (OON) provider on August 8, 2021 and
August 13, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the items were rendered by an out of network
provider, without prior authorization. Additionally, a recliner chair is not a covered benefit under your
contractual policy or by Medicare.
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 issue reimbursement from out-of-network providers only in cases involving
emergencies, out of area urgent care and pre-approved care. Additionally, Medicare will pay for durable
medical equipment that is mainly used to serve a medical purpose.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.
Additionally, a recliner chair is not a covered benefit under your contractual policy or by Medicare as it is not
classified as durable medical equipment that is mainly used to serve a medical purpose. We found no exception
that would require the Plan to issue reimbursement for these items. Therefore, we decided that the Plan does
not have to issue reimbursement for the seat lift mechanism, electric, any type (E0627) and the lift chair
(A9270) purchased from the out-of-network (OON) provider on August 8, 2021 and August 13, 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 transfer to an IRF is essential for your full recovery.
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary
services can safely be provided in a lower level of 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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by on September
14, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you went to see your primary care
physician only for an annual physical nothing else. The Plan denied your request. The Plan says an annual
physical was done along with a follow up for other services therefore an office copayment was 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 $15
copayment for per visit for PCP office visit.
You have been asked to pay a $15 copayment for an office visit. An office visit falls 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 an office visit provided by on September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgery provided on November 4, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the surgery. You say that you would like to appeal for denied services. The Plan denied your request. The Plan says the rendering provider is also the referring provider which is an out-of-network provider with no prior authorization. Also, the service provided was not urgent or emergent.

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 surgery provided on November 4, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim denture (D5810), surgical placements of implant
body (D6010), immediate denture (D5140), extractions (D7140) and unspecified removable prosthodontic
procedure (D5899) provided on June 9, 2021.
You asked the Plan to pay for the dental services. You say that these services were medically necessary and
important for your overall health. The Plan denied your request. The Plan says some of the requested services
are not covered. Some services are covered, and partial payment has been made, but you have met and
exceeded your $1,000 annual maximum for supplemental dental care. You are responsible for any remaining
charges after the annual maximum has been exhausted.
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 does not cover
services that are not listed in the dental benefits chart in the contract. There is an annual maximum of $1,000
for supplemental dental services. After the annual maximum is exhausted, any remaining charges are your
responsibility.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services have
exceeded your annual maximum for dental services. In addition, the dentures, implants and unspecified
prosthodontic procedure are not listed as covered services under your dental benefit. Therefore, we decided that
the Plan does not have to pay for the interim denture (D5810), surgical placements of implant body (D6010),
immediate denture (D5140), extractions (D7140) and unspecified removable prosthodontic procedure (D5899)
provided on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine (72125).  You asked the Plan to pre-approve a CT scan of the cervical spine. You say that the requested scan is a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage of the requested scan have not been met.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the cervical spine have not been met. Specifically, the treating physician in this case has indicated that a CT scan of the cervical spine is not necessary. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine (72125). Please contact your treating physician if you disagree with the decision.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on September 28, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that the first dentist could not perform the extraction, so you went to another dentist. The Plan denied your request. The Plan says the benefit limit for D0140 has already been exhausted.

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 one limited oral evaluation per calendar year. 

We looked at the file and Medicare rules. A limited oral evaluation was provided on September 8, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on September 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services you received on
October 14, 2021.
You asked the Plan to waive the copayment for the urgent care services. You say that you went to urgent care
on October 13, 2021 due to a skin tear on your arm. You were charged a copayment for that visit. You then
had to return the following day because the bandage came off and the wound was bleeding. You do not think
you should have to pay the copayment for the second visit because your arm was too loosely wrapped. 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 $45
copayment for each urgent care visit.
You have been asked to pay a $45 copayment for the urgent care services. This copayment applies each time
you go to the urgent care center, 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 urgent care services you received on October 14, 2021.