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

We decided that the Plan does not have to waive the copayment for the endoscopy provided on August 4, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that this was done in the doctor's
office, so you paid your $45 copayment. You say that you don't understand why you're getting this bill. 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 $400
copayment for surgery services at an in-network ambulatory surgical center.
You have been asked to pay $372.90, which is less than the standard $400 copayment for the endoscopy. The
endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers" benefit category. The records show the endoscopy was provided at an ambulatory
surgical center. 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 endoscopy provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from October 2, 2018 to October 8, 2018 with DRG 682.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG.
In this case, you billed the services provided October 2, 2018 to October 8, 2018 with diagnosis code N17.9 (Acute kidney failure, unspecified) as the principal diagnosis. 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 inpatient services at this DRG. Our reviewer says that the documentation does not support the principal diagnosis billed. Our physician reviewer found the enrollee resented to the hospital on 10/02/2018 for evaluation of generalized weakness. The medical record noted that the enrollee was found on the floor by the enrollee's wife and the enrollee was incontinent and vomited. Lab studies showed WBC 14.3 Hb 13.4, BUN 23, Creatinine 1.4, glucose 213, albumin 3.3. A chest x-ray was normal. A head CT showed no acute intracranial abnormality and a right frontal ventricular shunt catheter with grossly stable prominent ventricular size. The enrollee was admitted to the hospitalist service with a diagnosis of near syncope. The enrollee's symptoms improved with IV hydration. He had an echocardiogram and Cardiology consult that documented a NSTEMI and was treated with aspirin. The provider assigned N17.9 (Acute kidney failure, unspecified) as the principal diagnosis. The documentation did not support the assignment of N17.9 as the principal diagnosis. It was noted that the physician documented acute on chronic renal failure in the discharge note. While the enrollee's presentation warranted consideration of acute renal failure as a possible diagnosis, the diagnosis of acute renal failure was not supported by the clinical evidence. Therefore, the services were billed incorrectly.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate N17.9 as the principal diagnosis. We also note that the Plan has decided to pay this at a lower DRG. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from October 2, 2018 to October 8, 2018 with DRG 682.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally forthe dental services provided on June 22, 2020.You asked the Plan to pay additionally forthe dental services. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says they paid its $150 share for the services rendered on June 22, 2020 and you owe the remaining balance of $123.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.We looked at the file, the Plan's contract and Medicare rules. The Plan's contract shows that you have a supplemental dental benefit limit of $150 for non-Medicare covered dental services covered by the Plan. The file shows the Plan paid its $150 share for the services rendered on June 22, 2020.Therefore, we decided that the Plan does not have to pay additionally forthe dental services provided on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forurgent care services (81003, 99203, 36416, 99000) provided June 25, 2020.You asked the Plan to waive the copayment forthe urgent care services. You say that the copayment should be waived as you did not receive services on this date.The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for urgent care. You have been asked to pay a $30 copayment for the urgent care services. The urgent care services fall within the urgent care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 forurgent care services (81003, 99203, 36416, 99000) provided June 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 5, 2020.
You asked the Plan to waive the copayment for outpatient surgery. You say that you have these services in the provider's office and you should not be charged this amount just because of the provider's new building. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $200 copayment for outpatient surgery provided by an outpatient hospital facility. This provider is an outpatient hospital facility; therefore, the outpatient hospital surgery copayment applies to this claim. You have been asked to pay $200 copayment for outpatient surgery. Outpatient surgery 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 for outpatient surgery provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased out of network.
You asked the Plan to pay for this equipment. You say that the Plan should pay for this walker. The Plan
denied your request. The Plan says you did not have prior authorization to purchase equipment out of network.
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. You purchased equipment out of network without prior
authorization. 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 a walker purchased out of network.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for removal of residual tooth roots (D7250) and surgical removal of erupted tooth (D7210) provided on July 22, 2020.
You asked the Plan to pay for removal of residual tooth roots and surgical removal of erupted tooth. You say that the services should be covered. The Plan denied your request. The Plan says removal of residual tooth roots is not a covered benefit and you have exhausted your benefits for extractions.
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. You are allowed two extractions per a calendar year and services not listed in the Plan's EOC are not covered benefits. 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. Specifically, you have already exhausted your frequency limitations for extractions and code D7250 is not listed as a covered benefit in the Plan's EOC. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for removal of residual tooth roots (D7250) and surgical removal of erupted tooth (D7210) provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a commode chair and shower chair provided on August 21, 2020.
You asked the Plan to pay for commode chair and shower chair. You say that you needed these items due to your total knee replacement. The Plan denied your request. The Plan says the denial of payment for these items is correct, because these items are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. The file does not show that you are confined to a bed or room as defined by Medicare rules. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a commode chair and shower chair provided on August 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 26, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you went to urgent care before and paid that copayment. You say that this should be included in the $40 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 $10 copayment for Medicare-covered lab services. You have been asked to pay a $10 copayment for the laboratory services. Laboratory services 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 laboratory services provided on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing rendered on May 1, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing was not medically necessary. 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 pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee has adenocarcinoma of the lung diagnosed in 2018. Associated testing, including PDL and ALK, was completed. Despite therapy, brain metastases were identified in early 2020. Additional testing specifically related to the lung cancer, for which associated therapies are known, is medically necessary and reasonable. Panel testing, inclusive of testing that is not related to lung cancer, or for which there are no associated therapies, is not medically necessary or reasonable. The documentation does not support that the testing was reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 testing rendered on May 1, 2020. Local Coverage Article (LCA) A58192 referenced by the Plan was not effective on the date of service at issue and was not used in the determination.
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 on February 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 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 on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient dermatology office visit provided on July 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that please note you previously spoke with a plan representative who gave you an authorization number which was good for 1 visit from 6/22/2020 to 6/22/2021. Please reprocess accordingly to allow. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient dermatology office visit provided on July 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you have limited income and would like this copayment waived.The Plan denied your request. The Plan says the copayment applied correctly in this case.

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 $395 copayment per day for days 1 through 4 and a $0 copayment per day for additional days for inpatient hospital care. 

You have been asked to pay a total cost share of $1,185 for the 3 inpatient hospital days you received(3 days x $395 copayment). The services provided 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 the inpatient hospital care provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and periapical x-ray (D0220) provided by August 31, 2020.
You asked the Plan to pay for the dental services. You say that your regular dentist has retired. You say that your tooth cracked. You say that you had to seek care from a new dentist. The Plan denied your request. The Plan says 1 oral exam is covered per year. The Plan says that the frequency limit has been exceeded. The Plan says that periapical x-rays are not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 oral exam per calendar year has been exceeded. The record shows that the Plan paid for an oral exam that you received on January 21, 2020. Additionally, the periapical x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and periapical x-ray (D0220) provided by August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network genetic testing provided on May 11, 2020.You asked the Plan to pay forthis service. You say that this testing should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network genetic testing.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 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 forout of network genetic testing provided on May 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Aspirin and Nitroglycerin provided in an outpatient setting on July 23, 2020.
You asked the Plan to reimburse you for the self-administered drugs. You say that you received these same drugs in the emergency room in 2019. You say that when you appealed that date of service, the charges were overturned and paid. You say that they should be paid for the date of service in this case as well. The Plan denied your request. The Plan says the drugs that you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B when you receive them in an outpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to reimburse you for the Aspirin and Nitroglycerin provided in an outpatient setting on July 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital bed and lift provided on June 30, 2020, through July 1, 2020.You asked the Plan topay forthe hospital bed and lift. You say that you would like reconsideration for reimbursement of the supplies durable medical equipment.The Plan denied your request. The Plan says the records do not show an appropriate face-to-face encounter documented in the records to substantiate the need for these items nor a physician order for these items.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 does not contain a valid physician order for the supplies provided in this case. The record also indicates that you were informed that insurance would not be billed for these supplies and you would be responsible for payment.Therefore, we decided that the Plan does not have to pay forthe hospital bed and lift provided on June 30, 2020, through July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that due to the nature of your services you are unable to get prior authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 29, 2020 by an out of network (OON) provider.