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

We decided that the Plan does not have to waive the copayment for urgently needed services provided on
September 6, 2019.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the
charges because you received the bill 4 months later. The Plan denied your request. The Plan says the claims
were processed correctly and you are being charged the correct 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 $40
copayment for urgently needed services.
You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fall
within the urgently needed 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
urgently needed services provided on September 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood pressure monitor/blood pressure monitoring during an ambulance transport on October 2, 2019.
You asked the Plan to pay for a blood pressure monitor/blood pressure monitoring during an ambulance transport. You say that the enrollee's blood pressure was monitored during transport so the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee was not given a blood pressure machine and blood pressure monitoring is included in the ambulance fee schedule payment.
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 A4670 is automatic bp monitor, dial. We find that CPT code A4670 is not supported in the medical record. Specifically, the enrollee did not receive a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately payable. Based on this information, we decided that Medicare rules for coverage of a blood pressure monitor/blood pressure monitoring during an ambulance transport have not been met. Therefore, we decided
that the Plan does not have to pay for a blood pressure monitor/blood pressure monitoring during an ambulance transport on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 17, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requiresauthorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 thePlan. The Plan did not pre-approve the servicesat 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 a domiciliary, rest home visit provided on February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care that you provided on December 13, 2019.
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care that you provided on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray provided on February 17, 2020. You asked the Plan to waive the copayment for the chest x-ray. You say that you have never paid a copayment when going to this facility. You say that you are not supposed to be charged any copayments. The Plan denied your request. The Plan says the copayment applied 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 $40 copayment per provider, per date of service for routine radiology (x-ray, radiology, diagnostic services, ultrasounds). You have been asked to pay a $40 copayment for the chest x-ray. The chest x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the chest x-ray provided on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the  injection.
You asked the Plan to pay for the injection. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says contraceptive supplies are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that that services for the purposes of preventing conception, including services performed because a physician believes pregnancy would endanger the overall general health of the woman, are not considered to be reasonable and necessary for the diagnosis or treatment of illness or injury within the meaning of Section 1862(a)(1) of the Social Security Act. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Specifically, contraceptive supplies for the purpose of preventing conception are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 7, 2019. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says your Plan does not have out of network benefits unless an authorization is requested and approved. 
 
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 physician's services. 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 physician's services provided on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 5, 2020 to March 12, 2020. You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were discharged from a previous stay too soon and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $380 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from March 5, 2020 to March 12, 2020. Therefore, you are responsible to pay a $380 copayment for days 1-5 (March 5, 2020 to March 9, 2020). $380 (copayment) x 5 (inpatient days) = $1,900. You have been asked to pay the total copayment amount of $1,900 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay from March 5, 2020 to March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 17, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0480 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to 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 drug testing services provided to the enrollee on October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture provided on February 14, 2020.You asked the Plan to pay for the maxillary partial denture and mandibular partial denture. You say that your dentist had documents from the Plan saying these services were approved.The Plan denied your request. The Plan says these services are not covered under your contract under any normal circumstances.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 pay for the maxillary partial denture and mandibular partial denture provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis treatments provided from October 2, 2019 to October 30, 2019.
You asked the Plan to waive the coinsurance for the dialysis treatments. You submitted your bill for review. 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 in-network Medicare-covered benefits for outpatient dialysis treatments. You have been asked to pay a total of $204.83 for the dialysis treatments. The dialysis treatments fall within the "Services to Treat Kidney Disease" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
October 2, 2019
Dialysis
$290
20%
$58.00
October 4, 2019
Dialysis
$290
20%
$58.00
October 7, 2019
Dialysis
$290
20%
$58.00
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
October 9, 2019
Dialysis
$290
20%
$30.83 - This is where you met your maximum out-of-pocket amount
October 11, 2019
Dialysis
$290
20%
$0.00
October 14, 2019
Dialysis
$290
20%
$0.00
October 16, 2019
Dialysis
$290
20%
$0.00
October 18, 2019
Dialysis
$290
20%
$0.00
October 21, 2019
Dialysis
$290
20%
$0.00
October 23, 2019
Dialysis
$290
20%
$0.00
October 25, 2019
Dialysis
$290
20%
$0.00
October 28, 2019
Dialysis
$290
20%
$0.00
October 30, 2019
Dialysis
$290
20%
$0.00
Total
$204.83
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 dialysis treatments provided from October 2, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an office visit provided on January 21, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was a visit to receive results. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for primary care provider visits. The medical records show that you had an office visit at your primary care provider's office on January 21, 2020. There is no indication that an urgent care visit was rendered. Therefore, you cannot be asked to pay an urgent care visit copayment. The Plan says you must pay a $65 copayment for an office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for primary care provider visits. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on January 21, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe perfusionist services provided on November 25, 2019.You asked the Plan to pay forthe services provided. You say that the charges are for the perfusionist that setup and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility.Therefore, we decided that the Plan does not have to pay forthe perfusionist services provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services coded S9500 provided from December 25, 2019 to December 31, 2019.You asked the Plan to pay forthe home infusion therapy services. 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 a covered benefit.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 S9500 is home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9500 is not supported in the medical record. Specifically, code S9500 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met.Therefore, we decided that the Plandoes not have to pay forthe home infusion therapy services coded S9500 provided from December 25, 2019 to December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 72170) provided to the enrollee on November 20, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 72170 (1 unit) remains not supported.
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 72170 is "radiologic examination, pelvis; 1 or 2 views." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found there is no separate report for a 1 or 2 view pelvis exam (CPT 72170) therefore absent same there is no support for a separate charge for additional examination of the pelvis. 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 for radiology services (CPT 72170) provided to the enrollee on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on September 25, 2019 to September 28, 2019. 
 
You asked the Plan to pay for a chiropractic office visit. You say that these services should be covered because the provider is in-network. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan. 
 
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on September 25, 2019 to September 28, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 10, 2019 to July 23, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the attached records support treatment at the level of the care billed. The Plan denied your request. The Plan says that that the enrollee did not require or receive care at an inpatient level to support the authorization of the request.
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 pay for acute inpatient hospital care. Our reviewer says that inpatient hospital care was medically necessary. Our doctor found that on admission, the enrollee had generalized weakness and ambulatory dysfunction. After her condition stabilized and improved, she was discharged home with close outpatient follow-up. The record showed 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 10, 2019 to July 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22867).
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 pre-approve insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22867).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for pre-operative care for the closed treatment of hip dislocation provided on July 21, 2019.You asked the Plan to pay for the pre-operative care. You say that you would like reconsideration because the services rendered were medically necessary.The Plan denied your request. The Plan says a charge submitted with modifier 54 is a charge for surgical care only (intraoperative care).The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of closed treatment of hip dislocation (27250-54) have not been met. Specifically, the medical record did not have a written copy of the written transfer agreement. The services at issue were for pre-operative care. Use of Modifier 54 is therefore, not supported.Therefore, we decided that the Plan does not have to pay for pre-operative care for the closed treatment of hip dislocation provided on July 21, 2019.