Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance the Part B injection provided on September 10, 2019
You asked the Plan to waive the coinsurance the Part B injection. You say that the provider is in-network. 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $229.20 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,146.24. ($1,146.24 x 20% = $229.20). The Part B injection falls within the "Medicare Part B Prescription Drugs" benefit category. The record shows the coinsurance was applied with the in-network benefit.
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 the Part B injection provided on September 10, 2019
Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information regarding the allowed amount of the claim. Please contact the health plan to receive a corrected Explanation of Benefits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room services provided September 20, 2019.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room Services. The Emergency Room Services falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for Emergency Room services provided September 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 8,
2019 through October 10, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC 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).
Review of the file shows that you were admitted on October 8, 2019 and discharged on October 10, 2019. You
were asked to pay a $300 copayment per day from October 8, 2019 through October 9, 2019, days 1-2 of your
inpatient hospital care. You were discharged on October 10, 2019 and there was no copayment charge for the
day of discharge. Per your contract there is a $300 copayment per day required for days 1-6. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for inpatient hospital care from October 8, 2019 through October 10,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 15, 2020.You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford this 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 $150 copayment for each Medicare-covered one-way trip by ground transportation. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe supply allowance for a therapeutic continuous glucose monitor provided on September 30, 2019.You asked the Plan to pay forsupply allowance for a therapeutic continuous glucose monitor. You say that the supplies were medically necessary.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the supplies. Based on this information, we decided that Medicare rules for coverage of supply allowance for a therapeutic continuous glucose monitor have not been met.Therefore, we decidedthat the Plan does not have to pay forthe supply allowance for a therapeutic continuous glucose monitor provided on September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) and comprehensive oral exam (D0150) provided from January 16, 2020 to January 17, 2020.You asked the Plan to pay for the dental services. You say that you contacted the plan prior to your appointment to ensure that the services you were scheduled to receive would be covered. You say that the plan representative advised that they would be. You say that you did your due diligence and should not be charged for these services.The Plan denied your request. The Plan says the comprehensive oral exam and bitewing x-rays are not listed as covered services. 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 dental services you received are not among those covered under this benefit. The record shows that the plan representative advised that the specific dental services that were covered were located on page 65 of the Evidence of Coverage. They also advised specifically that a comprehensive oral exam would not be covered.Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) and comprehensive oral exam (D0150) provided from January 16, 2020 to January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 28, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider and the referring provider in this case are not network providers with the Plan. 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 laboratory services provided on February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ophthalmic diagnostic imaging service provided on January 20, 2020.You asked the Plan to waive the copayment forthe ophthalmic diagnostic imaging test . You say that this claim should be reprocessed with a $0 cost share based on your supplemental coverage. 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 $65 copayment for each covered diagnostic procedure or test at a network doctor's office. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $65 copayment for the ophthalmic diagnostic imaging test.You have been asked to pay a $37.90 copayment for the ophthalmic diagnostic imaging test. The ophthalmic diagnostic imaging test 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 thePlan. Therefore, we decided that the Plan does not have to waive the copayment forthe ophthalmic diagnostic imaging service provided on January 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that you have had several falls recently which you have
discussed with your primary care physician. You say that the requested items are not for hygienic purposes but
are for injury prevention. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because
they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the knee x-ray (73562) and outpatient visit (99213) provided on February 4, 2020.. You say that you would like reconsideration because you were not aware that this provider was not in-network. The Plan denied your request. The Plan says services not within network, therefore, these out-of-plan services are not a benefit of the member's plan.
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 has network providers available who can provide 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 medical services provided on February 4, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forchemotherapy administration services (CPT 96416) provided to the enrollee on October 14, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the time over which the infusion was administered is not documented, no start nor stop times were included in order to support the denied code.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 96416 is "chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump."We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the medical records provided do not include documentation of a start and stop time to support chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump being performed on October 14, 2019, therefore this service cannot be verified.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 services have not been met.Therefore, we decided that the Plan does not have to pay forchemotherapy administration services (CPT 96416) provided to the enrollee on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided January 10, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for days 1-6 for Inpatient Care. You have been asked to pay a $275 copayment for Inpatient Care. 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 forinpatient hospital care provided January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services
cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the
drug testing services provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on January 1, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99232 is not separately payable.
The Plan must follow Medicare rules. The rules say that Medicare pays a physician for only one hospital visit per day for the same patient. We looked at the file and Medicare rules. The file shows that the Plan previously paid procedure code 99233 (subsequent hospital care) for this enrollee by a provider with the same specialty for the date of service at issue. Procedure code 99232 can therefore not be paid as well. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on January 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99284) provided on September 11, 2019.
You asked the Plan to pay for the emergency room services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for emergency room services (99284) provided on September 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 3, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 laboratory services provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on January 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider does not
participate with the plan.
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 has network providers
available who can provide 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 medical services provided to you by an out-of-network provider on
January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forphysician services (CPT 67500) provided to the enrollee on January 8, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis surgical code was submitted by a provider with an anesthesia specialty.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 67500 is "Retrobulbar injection; medication (separate procedure, does not include supply of medication)."We asked our coding 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 payfor the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT 67500 is a surgical code. When a provider billing this service has a specialty in anesthesiology, the CPT code should be croswwalked to the appropriate anesthesia code [00100 -01999], therefore this service is not validated as billable by this provider based on the medical records provided.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forphysician services (CPT 67500) provided to the enrollee on January 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skin tag removal provided on December 4, 2019. You asked the Plan to pay for the skin tag removal. The Plan denied your request. The Plan says this was not medically necessary. The Plan follows Medicare rules. Medicare rules say that benign skin removal is considered non-cosmetic when the above criteria 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 pay for the skin tag removal. Our reviewer says that the requested services were not medically reasonable and necessary. Our physician reviewer found that the skin tag removal in question was cosmetic and not a medical problem. 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 skin tag removal have not been met. Therefore, we decided that the Plan does not have to pay for the skin tag removal provided on December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-rays (D0230 x 4) provided on January 28,
2020.
You asked the Plan to pay for the dental service. You say that you did not ask for the x-rays. You also say that
you were not told that the x-rays would not be covered. The Plan denied your request. The Plan says periapical
x-rays are not a covered service.
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 periapical x-rays are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical xrays
(D0230 x 4) provided on January 28, 2020.