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 for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.  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. The enrollee does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At the enrollee's current level of function, she does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. She needs routine physical therapy (PT) and occupational therapy (OT) in a lower intensity level. While the enrollee may benefit from PT, and OT, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  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 does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different 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 hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary at this time. The Plan denied your request. The Plan says inpatient hospital care is not medically reasonable and necessary.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case.  Our physician reviewer found that the review indicates that you are an 80-year-old female with a history of hypertension, carotid artery stenosis, chronic obstructive pulmonary disease, vertigo, and hypothyroidism. The record sent by your provider indicates she presented to the emergency room on February 6, 2022, with complaints of dizziness, a headache, and eye pain as well as a blood pressure which was too high. You had a blood pressure that was originally 146/67 at 10:53 but then was 160/72 at 15:36. The records also say that you had a transient reading of 212/83 which was treated with a dose of intravenous medication achieving "successful reduction of hypertension." You were monitored overnight with blood pressure the next morning of 152/73. The laboratory blood tests showed a normal kidney function, normal liver tests, and normal hemoglobin. Testing was negative for a myocardial infarction or congestive heart failure. The computed tomography scan of your brain was normal. You were stable on February 7, 2022 and were discharged home with primary care physician follow-up. The review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital laboratory services provided on November 5, 2021.  

You asked the Plan to waive the copayment for the outpatient hospital lab services. You say that the services should be covered as you stayed in the doctor's office. The Plan denied your request. The Plan says the cost-sharing applied correctly as there is a copayment for laboratory services regardless of if you left the office or not.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient hospital services.     

You have been asked to pay a $40 copayment for outpatient hospital laboratory services. Laboratory services fall within the Outpatient hospital 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 outpatient hospital laboratory services provided on November 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), abutment supported cast metal crowns (D6063), implant supported porcelain/ceramic crowns (D6065), and pontics (D6240).  You asked the Plan to pre-approve the endosteal implant, abutment supported cast metal crowns, implant supported porcelain/ceramic crowns, and pontics. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not covered under your benefit plan.  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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant (D6010), abutment supported cast metal crowns (D6063), implant supported porcelain/ceramic crowns (D6065), and pontics (D6240).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 13, 2020.  You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).  We looked at the file and Medicare rules. The testing at issue was billed with POS 11 for an office setting, but the records show that the sample was taken in a nursing facility. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90853) provided on February 10, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, no records were provided to document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90853) provided on February 10, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the hospital observation services you had on June 8, 2021.  

You asked the Plan to reduce the copayment for the hospital observation services. You say that you said that you went to the emergency room at the request of your doctor.  The hospital wanted you to stay overnight but there were no beds available.  You said that you had to stay in the emergency department.  Because of this, you believe you should only pay the $120 copayment for the emergency department, not the higher observation 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 $150 copayment for outpatient hospital observation services.   

You have been asked to pay a $150 copayment for the hospital observation services. The billing records show that you were placed in observation in the hospital. You can be in observation even if your bed is in the emergency department. 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 hospital observation services you had on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on October 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the enrollee had a change in Medicare plans that was not completed. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 13, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October
18, 2021.

You asked the Plan to waive the copayment for the laboratory services. You say that you have never been
responsible for blood work in the past. 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 $45
copayment for lab services provided at an outpatient hospital.

The file lists the place of service (POS) as an outpatient hospital facility. Therefore, you have been asked to pay
$28.83, which is less than the $45 copayment for the laboratory services. The 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 October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on October 28, 2021.  You asked the Plan to pay for the dental services. You say that you should not have to pay for these services. You say that these services are covered under your insurance. You say that you cannot afford this bill. You also say that you were misinformed on your benefits. The Plan denied your request. The Plan says the frequency limits have been exceeded.  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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for the comprehensive oral evaluation and complete series x-ray that you received on September 25, 2020, less than 3 years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) provided on October 28, 2021.   Your complaint about being given incorrect information regarding your benefits 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 psychiatry telehealth services (99443) provided on February 26, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for psychiatry telehealth services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services are not covered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan will never cover telehealth services when billed by an OON provider.  The requested provider in this case is not a network provider with the Plan. The services at issue were telehealth services that are not covered when performed by an OON provider. Therefore, we decided that the Plan does not have to pay for psychiatry telehealth services (99443) provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).  You asked the Plan to pre-approve the endosteal implants. You say that the enrollee lost tooth #'s 2, 3, 18, and 19 due to periodontal disease. You also say that the enrollee needs to replace tooth #'s 2, 3, 18, and 19 with dental implants in order to restore masticatory function. The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan.  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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayments for specialist office visits provided from August 6, 2021, to August 24, 2021.  You asked the Plan to reduce the copayments for the specialist office visits. You say that you feel that you should be paying the PCP copayment since you were unaware that they were licensed as a specialist. 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 $45 copayment for each visit with a specialist.   The file shows that the provider is a pulmonologist, which is considered a specialty practice. Therefore, you have been asked to pay a $45 copayment for each of the specialist office visits for a total of $90.  The specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayments for specialist office visits provided from August 6, 2021, to August 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an endoscopy and laboratory services provided on September 22, 2021.  You asked the Plan to waive the copayment for the endoscopy and laboratory services. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 and a $10 copayment for Outpatient hospital services.     You have been asked to pay a $325 copayment for the endoscopy and a $10 copayment for laboratory services. Endoscopies and laboratory services fall within the Outpatient hospital 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 an endoscopy and laboratory services provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0480, 83789, 80307) provided on April 15, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for drug testing. You say that you would like the Plan to review and accept this claim as a medical necessity appeal. The Plan denied your request. The Plan says this provider is a non-network provider who does not work with the member's Plan, and the member was referred by a provider who also does not work with the member's Plan. The Plan also says that the member's primary care physician did not refer for services, and there was no medical necessity for an out-of-network provider, such as an urgent or emergency 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. Therefore, we decided that the Plan does not have to pay for drug testing (G0480, 83789, 80307) provided on April 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 27, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided and you were made aware of the copayment beforehand.  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 Physician/Practitioner services, including doctor's office visits.       You have been asked to pay a $30 copayment for a specialist office 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 a specialist office visit provided on October 27, 2021.