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

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that laboratory services furnished by an independent laboratory are covered under SMI if the laboratory is an approved Independent Clinical Laboratory. However, as is the case of all diagnostic services, in order to be covered these services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. You can find this rule in the Medicare Claims Processing Manual, Chapter 16, Section 10.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia and each subsequent 15 minute increment of deep sedation/general anesthesia provided on January 7, 2020.
You asked the Plan to pay for the deep sedation/general anesthesia services. The Plan denied your request. The Plan says these services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the first 15 minutes of deep sedation/general anesthesia and each subsequent 15 minute increment of deep sedation/general anesthesia provided on January 7, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care represented by CPT code 99220
provided on October 3, 2019.
You asked the Plan to pay for CPT code 99220. You say that the records provided support that the service in
dispute was provided and warrants payment. The Plan denied your request. The Plan says payment for the
service in dispute was included in payment made on CPT code 99221.
Plan must follow Medicare rules. The rules say that when a NCCI edit exists between two codes, generally
only the Column 1 code is payable, unless the modifier indicator for the code is 1 and a clinically appropriate
modifier is used to bypass the edit.
CPT code 99220 is a Column 2 code in relation to code 99221. CPT code 99220 was not billed with a clinically
appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay
for initial observation care represented by CPT code 99220 provided on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 23, 2020.
You asked the Plan to pay for the ambulance services. You say that the provider chose a code so you would be responsible for the charge. The Plan denied your request. The Plan says the records show you refused a transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the services provided on February 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on January 30, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not include any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit (99203) provided on February 18, 2020.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration because the member qualifies as a new patient. The Plan denied your request. The Plan says this code is inappropriate for an established patient.
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 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99203 is not supported in the record. Specifically, the documentation submitted indicates that another outpatient visit rendered by a physician in the same group/specialty was provided within three years of this new patient evaluation. Based on this information, we decided that Medicare rules for coverage of the outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay for an outpatient visit (99203) provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services that you provided on May 29, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says there is no authorization and the provider is out-of-network 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 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 nurse practitioner services that you provided on May 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from December 22, 2019 to December 31, 2019 by a provider that does not participate in the Medicare program.You asked the Plan to pay for home health services. You say that these claims should be paid.The Plan denied your request. The Plan says these services were not provided by a certified Medicare provider.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The provider that the enrollee received these services from is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pay for home health services provided from December 22, 2019 to December 31, 2019 by a provider that does not participate in the Medicare program.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 13, 2020.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on February 6, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were advised that you could only
go to the ER. You say that the Plan should pay the copayment. 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 $75
copayment for Medicare-covered emergency room visits.
You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the "Emergency Care"
benefit category. The records show that you were treated for a head wound in the ER. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the ER visit provided on February 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe upper GI endoscopy provided on January 1, 21, 2020.You asked the Plan to waive the copayment forthe upper GI endoscopy. 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 a $300 copayment for outpatient surgery services. You have been asked to pay a $300 copayment for the upper GI endoscopy. The upper GI endoscopy 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 forthe upper GI endoscopy provided on January 1, 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 9, 2020 to March 10, 2020.You asked the Plan to waive the copayment for inpatient hospital care. You say that you were in the intensive care unit after a surgery 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 $325 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay on March 9, 2020 to March 10, 2020. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for inpatient hospital care. Inpatient hospital care 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 inpatient hospital care provided from March 9, 2020 to March 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 3, 2020.You asked the Plan to pay for these services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 physician services provided on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation and panoramic x-ray provided on January 16, 2020 by an OON provider.You asked the Plan to pay forproblem focused limited oral evaluation and panoramic x-ray. You say that this provider is in network.The Plan denied your request. The Plan says the services were rendered by a non-contracted provider. The Plan also says that you contacted the Plan prior to the services being rendered and were told that this treating provider is OON.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 inthis case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation and panoramic x-ray provided on January 16, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hand finger orthosis provided on February 11, 2020.You asked the Plan to pay for the hand finger orthosis (L3930). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the documentation submitted did not include an itemized shipping/billing invoice or proof of delivery indicating the specific supplies dispensed.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the hand finger orthosis provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lumbar injection and trigger point injection provided from December 9, 2019 through December 17, 2019.
You asked the Plan to waive the copayment for the lumbar injection and trigger point injection. You say that the charge is very high for you to pay. You say that you hope the amount can be changed. 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 $300 copayment for each Medicare-covered outpatient surgical service. You have been asked to pay a $300 copayment for the lumbar injection and trigger point injection. The lumbar injection and trigger point injection falls within the "Outpatient hospital services" benefit category. The injections are considered a surgical procedure. 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 lumbar injection and trigger point injection provided from December 9, 2019 through December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Gingival Irrigation (D4921) and dental medication (D9630) provided January 18, 2020 to January 20, 2020.
You asked the Plan to pay for the Gingival irrigation and dental medication.. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits under your dental coverage.
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 Gingival Irrigation (D4921) and dental medication (D9630) provided January 18, 2020 to January 20, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the fluorodeoxyglucose injection provided on January 3, 2020.You asked the Plan to waive the copayment forthe fluorodeoxyglucose injection. You say that you've never been billed more than the copayment before. You say that no diagnostics took place.The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for medical supplies from a provider other than a medical supply provider.We looked at your contract with the Plan. We did not see where the contract says enrolleesmust pay a $35 copayment for medical supplies. The Plan contract does not clearly say how much enrollees must pay for medical supplies from a provider other than a medical supply provider. The fluorodeoxyglucose injection is considered a medical supply. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information.Therefore, we decided that the Plan has to waive the copayment forthe fluorodeoxyglucose injection provided on January 3, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the electric seat lift provided on October
15, 2019.
You asked the Plan to waive the coinsurance for the electric seat lift. You say that you are requesting a
payment for the full amount of your costs. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for durable medical equipment from an in-network durable medical equipment
provider.
The enrollee has been asked to pay $50.63 which is 20% of the allowed amount for the electric seat lift. The
allowed amount is $253.13. ($253.13 x 20% = $50.63). The electric seat lift falls within the "Durable medical
equipment (DME) and related supplies" benefit category.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the coinsurance for the electric seat lift provided on October 15,
2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on November 15, 2019 and November 20, 2019.
You asked the Plan to waive the copayments for ambulance services. You say that you disagree with the charges because they should have been included in your stay. 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 $220 copayment for ambulance services. You received ambulance services on November 15, 2019. Therefore, you are responsible to pay the $220 copayment. You received ambulance services on November 20, 2019. Therefore, you are responsible to pay the allowed amount of $174.80, which is less than the $220 copayment. The total amount you owe is: $394.80. You have been asked to pay the total copayment amount of $394.80 for ambulance services. Ambulance services fall 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 copayments for ambulance services provided on November 15, 2019 and November 20, 2019.