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

We decided that the Plan does not have to pay for physician's services provided on March 21, 2021.

You asked the Plan to pay for physician's services. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on March 19, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on March 21, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99283) provided on August 14, 2020.
You asked the Plan to pay for an emergency room visit. You say that this should be covered. The Plan denied your request. The Plan says this is not separately payable from the critical care provided on the same date of service.
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, we have confirmed that code 99283 has a bundled relationship with code 99291 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99283) provided on August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 14, 2021.
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 the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electro-acupuncture device/auricular stimulator.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says stimulation of auricular acupuncture points is specifically non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. 

The requested device is specifically not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve an electro-acupuncture device/auricular stimulator.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the emergency room (ER) visit you had on March 10, 2021, the ambulance transport you had on March 10, 2021, the lab services you had on March 29, 2021, and April 8, 2021, and the outpatient cardiac catheterization procedure you had on Apri1 13, 2021.
You asked the Plan to waive the cost sharing for the ER visit, ambulance services, lab services, and outpatient cardiac catheterization procedure. You say that you thought having this plan would mean a lower cost sharing amount as opposed to Medicare. The Plan denied your request. The Plan says you were charged these cost sharing amounts appropriately.
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 room visits. The contract also says that enrollees pay a $220 copayment for ambulance services, a $10 copayment for lab services and 20% coinsurance for diagnostic procedures and tests You have been asked to pay a $90 copayment for the ER visit, a $220 copayment for the ambulance services, a $10 copayment for each of the lab services, and 20% coinsurance for the outpatient cardiac catheterization procedure. The cardiac catheterization is considered a diagnostic procedure. This means that you have been asked to pay the correct amounts 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 cost sharing for the emergency room (ER) visit you had on March 10, 2021, the ambulance transport you had on March 10, 2021, the lab services you had on March 29, 2021, and April 8, 2021, and the outpatient cardiac catheterization procedure you had on Apri1 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 6, 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 the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 6, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on October 15, 2020 and October 16, 2020.

You asked the Plan to pay for the subsequent hospital care. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 subsequent hospital care provided on October 15, 2020 and October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography, maxillofacial area; without contrast material (70486) and the office visit (99214) rendered by the out-of-network (OON) provider on March 24, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 computed tomography, maxillofacial area; without contrast material (70486)
and the office visit (99214) rendered by the out-of-network (OON) provider on March 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February 18, 2021, to February 25, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was billed with an invalid type of bill code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be paid as billed due to an issue with the type of bill code. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from February 18, 2021, to February 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from January 16, 2021, to January 29, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was submitted with an invalid type of bill code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, this claim was submitted with an invalid type of bill code. 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 home health services provided to the enrollee from January 16, 2021, to January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the colposcopy rendered on March 10, 2021.
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 the services were not billed with a proper diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary
diagnosis code. 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 colposcopy rendered on March
10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for the outpatient physician visits provided from March 2, 2021, to March 3, 2021.
You asked the Plan to waive the co-payments for the outpatient physician visits. You say that you were billed in error. You say you only saw the doctor for 10 minutes and you never had an office visit. The Plan denied your request. The Plan says you have been asked to pay 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 co-payment for provider and professional services at an in-network specialist's office.
You have been asked to pay a $25 co-payment for each of the outpatient physician visits. The outpatient physician visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you had two cardiology consultations while you were under observation. 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 co-payments for the outpatient physician visits provided from March 2, 2021, to March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82274, 82656, 83520, 83631, 87338) provided November 5, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 82274, 82656, 83520, 83631, & 87338 are not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82274, 82656, 83520, 83631, 87338) provided November 5, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 22, 2021.
You asked the Plan to pay for the physician's services. 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. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on March 19, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services
provided on March 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80299, 80307, 82542, 83789,
G0480) rendered by the out-of-network (OON) provider on April 19, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 laboratory services (80299, 80307, 82542, 83789, G0480) rendered by the
out-of-network (OON) provider on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the magnetic resonance imaging (MRI) of the arm you had on April 15, 2021.

You asked the Plan to reduce the copayment for the MRI. You say that you called to check the copay and you were told it was only $45. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that there are no phone records showing that you called the Plan prior to the services to be advised of a copayment.

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 $225 copayment for diagnostic radiology services other than computed tomography (CT) scans.

You have been asked to pay a $225 copayment for the MRI. The MRI falls within the diagnostic radiology services other than computed tomography (CT) scans 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 copayment for the magnetic resonance imaging (MRI) of the arm you had on April 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 11, 2020 to December 31, 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 the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with one of three Q codes. 
We looked at the file and Medicare rules. The file shows that the home health claims were not billed with one of the three required Q codes. 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 home health services rendered from December 11, 2020 to December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 18, 2021.
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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that post-surgical management services are included in the global surgical package. 
We looked at the file and Medicare rules. Billed procedure code 41112 (excision of lesion of tongue with closure; anterior two-thirds) was billed within the 90-day post-operative global surgical period for major surgical procedure, also code 41112, billed on December 4, 2020. Payment for the post-surgical management is included in the global surgical period. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305, 88312, 88342, 88112, 88313) provided on April 21, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan also says that services were provided by an out-of-network provider without 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 records provided for review also show that the enrollee was referred by a non-participating provider. 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 laboratory services (88305, 88312, 88342, 88112, 88313) provided on April 21, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on December
13, 2020.
You asked the Plan to pay for this transport. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim
must be submitted to Original Medicare first for review.
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
ambulance transport provided to the enrollee on December 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oral device provided on March 3, 2021.

You asked the Plan to waive the coinsurance for the oral device. You say that you and the provider were told different amounts for payment by the customer service department. The Plan denied your request. The Plan says you have been asked to pay 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 30% coinsurance per out-of-network (POS) item. 

You have been asked to pay $90 which is 30% of the allowed amount for the oral device. The allowed amount is $300. ($300 x 30% = $90.) The oral device falls within the "Durable medical equipment (DME) and related 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 coinsurance for the oral device provided on March 3, 2021.