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

We decided that the Plan does not have to waive the copayments for the laboratory services rendered on January 30, 2019 to April 3, 2019.You asked the Plan to waive the copayments for these services. You say that the enrollee did not have copayments prior to this year.The Plan denied your request. The Plan says the copayments were 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $5 copayment for Medicare-covered laboratory tests. Review of the file shows that the enrollee received laboratory services for five dates of service from January 30, 2019 to April 3, 2019. the enrollee has been asked to pay a $5 copayment per date of service for these services for a total of $25. These services fall within the Medicare-covered laboratory tests 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 copayments for the laboratory services rendered to the enrollee on January 30, 2019 to April 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe breast ultrasound provided on May 30, 2019.You asked the Plan to waive the copayment forthe breast ultrasound. You say that you thought this was only a mammogram. You say that you were unaware you would be charged for an ultrasound.The Plandenied 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 Planclearly says that you must pay $250 per day for Medicare-covered diagnostic radiology services. Diagnostic  radiology services include ultrasounds, nuclear cardiac imaging, PET, MRI and CT scans.You have been asked to pay $75.55, which is less than the standard $250 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the ultrasound was performed. 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 breastultrasound provided on May 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on August 20, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges because you were admitted to the hospital.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 $65 copayment for emergency care. This copayment is waived if you are admitted to the hospital within 24 hours with the same condition.You had an ER visit provided on August 20, 2019. The record shows that you were admitted to the hospital with a separate condition. Therefore, you are responsible to pay the $65 copayment. You have been asked to pay a $65 copayment for an ER visit. An ER visit 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 foran ER visit provided on August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography provided to the enrollee on June 10, 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 the enrollee sough non-emergent/urgent services with a non-contracting provider.
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 rendering 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 mammography provided to the enrollee on June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the acupuncture (97813, 97814) and the office visits (99213) provide from May 1, 2019 to August 27, 2019.
You asked the Plan to issue reimbursement for these services. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under your policy.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to issue reimbursement for the acupuncture (97813, 97814) and the office visits (99213) provided May 1, 2019 to August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 8, 2018.
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 covered when billed by a chiropractor.
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. The provider submitted a claim for procedure codes 99213 (office visit) and 97014 (electrical stimulation therapy). Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on October 8, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe colonoscopy with biopsy provided on July 19, 2019.You asked the Plan to waive the coinsurance forthe colonoscopy. You say that you feel that you are high risk and this was necessary. You say that you should not have to pay.The Plan denied your request. The Plan says the coinsurance 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 20% of the total cost for each Medicare-covered service provided in an outpatient hospital or an ambulatory surgical center.You have been asked to pay $246.84, which is 20% of the allowed amount for the colonoscopy. The allowed amount is $1,234.22 (20% x $1,234.22 = $246.84).The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that two polyps were removed, which makes this 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 coinsurance forthe colonoscopy with biopsy provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 the enrollee by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on May 5, 2019.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 covered.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on May 5, 2019
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 16, 2019.You asked the Plan to waive the copayment for the ED visit. You say that they never looked at your foot. You say that you left with your foot still hurting.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 $90 for each Medicare-covered emergency room visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you received treatment in the ED. 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 ED visit provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services provided on July 1, 2019 to July 19, 2019 by out of network provider, "the provider" .You asked the Plan to pay forchiropractic services. You say that you were told these services would be covered.The Plan denied your request. The Plan says these services were not authorized.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 services.Therefore, we decided that the Plan does not have to pay forthe chiropractic services provided on July 1, 2019 to July 19, 2019 by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided by the provider on February 25, 2019.
You asked the Plan to pay for assistant at surgery services. You say that the surgeon and facility are both in-network and the procedure codes are payable to an assistant surgeon. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider type is not payable by Medicare for assistant at surgery services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided by the provider on February 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay foroutpatient hospital services provided to the enrollee on July 19, 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 the deductible had not been met.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 $750 deductible for in-network outpatient hospital services. You have been asked to pay a $750 deductible for the services. the services falls within the in-network outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plandoes not haveto pay foroutpatient hospital services provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services for an office visit and a visual field examination provided on June 27, 2019.You asked the Plan to pay forthe physician's 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.Therequested 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 forphysician's services for an office visit and a visual field examination provided on June 27, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for anesthesia services (99100 and 00811) provided on May 10, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the service was billed incorrectly and claims require CPT/HCPCS codes.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has not substantiated their denial. The Plan states that the claim form requires HCPCS/CPT codes, but the provider appears to have billed with HCPCS/CPT codes. Therefore, we decided that the Plan has to pay for anesthesia services (99100 and 00811) provided on May 10, 2019.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: Favorable

We decided that the Plan has to hold you harmless forthe services (CPT 99212) provided to you on June 11, 2019.You asked the Plan to hold you harmless forthe services. The Plan denied your request. The Plan says that this is included in the payment for the surgery services.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. "the plan" follows these rules.You were referred for the services by "the referrer". "The referrer" is a contract provider. The file does not show that "the plan" provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by "the plan" .Therefore, we decided that the Plan has to hold you harmless forthe services (CPT 99212) provided to you on June 11, 2019.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical arthroscopy services provided to enrollee on January 21, 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 this case involves an inappropriate billing of CPT 29823.
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 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive." 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 coding reviewer found CPT code 29823 is not supported by the medical record. According to NCCI rules, the debridement is included in the other procedures performed during this episode of care and shall not be reported separately. 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 Plan does not have to pay for surgical arthroscopy services provided to enrollee on January 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a Hepatitis B vaccine (90746) and administration (90471) provided on May 21, 2019.
You asked the Plan to pay for a Hepatitis B vaccine and administration. You say that this should be covered because you have diabetes. The Plan denied your request. The Plan says that your Part D prescription drug benefit is responsible for this vaccine.
The Plan follows Medicare rules. Medicare rules say that Hepatitis B vaccines are reasonable and necessary for the prevention of illness for people diagnosed with diabetes mellitus. We looked at the file and Medicare rules. The record shows that you have been diagnosed with diabetes mellitus. This means that you are high risk for Hepatitis B and meet Medicare criteria for coverage of the Hepatitis B vaccine. Therefore, we decided that the Plan has to pay for a Hepatitis B vaccine (90746) and administration (90471) provided on May 21, 2019.
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 medical services provided to "the beneficiary" by an out-of-network provider on May 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 forthe medical services provided to "the beneficiary" by an out-of-network provider on May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to "the beneficiary" by an out-of-network provider on August 12, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says there is no network deficiency for these services.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 forthe medical services provided to "the beneficiary" byan out-of-network provider on August 12, 2019.