Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe phlebotomy service provided on January 27, 2020.You asked the Plan to reduce the copayment forthe phlebotomy service. You say that you have never had to pay this much before for a phlebotomy service. 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 $275 copayment for all other services at an in-network outpatient hospital services (including diagnostic colonoscopy). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $275 copayment for the phlebotomy service.You have been asked to pay a $128.55 copayment for the phlebotomy service. The phlebotomy service 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 reduce the copayment forthe phlebotomy service provided on January 27, 2020. Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe services from December 17, 2019 through December 27, 2019.You asked the Plan to waive the copayment forthe services. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received two (2) in-network inpatient hospital admissions and in-network ambulance services from December 17, 2019 through December 27, 2019. You are asked to pay a $250 copayment for each inpatient admission and a $100 copayment for the ambulance services. 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 services from December 17, 2019 through December 27, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient services provided on March 12, 2020 by an out of network (OON) provider.You asked the Plan to pay foroutpatient services. You say that you told the doctor's office that you had a different plan. You say that you were told multiple times that these services would be covered.The Plan denied your request. ThePlan says no prior authorization was obtained.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 foroutpatient services provided on March 12, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 8, 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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection (87631) provided on February 17, 2020.
You asked the Plan to pay for infectious agent detection. You say that you should be reimbursed for this service. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Medical records were not submitted to show that this service was performed and was medically necessary. Without this documentation, it cannot be determined that criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of infectious agent detection have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection (87631) provided on February 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D6740x1) provided January 30, 2020.
You asked the Plan to pay for the dental service. You say that 1 tooth was extracted and 2 teeth was prepared to have a crown put on. Bridge included 2 crowned teeth and 2 in between and all was denied. Den 184 shows D2783 is covered at 30%. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.
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. The plan allows coverage for 1 crown per year. The plan has approved for one crown for this date of service. Therefore the second crown is not covered. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D6740x1) provided January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pathology services provided by a participating provider on March 4, 2020.
You asked the Plan to waive the copayment for pathology services. You say that you have never had a copayment for lab work before. 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 $5 copayment for outpatient diagnostic tests/lab services. You have been asked to pay a $5 copayment for pathology services. The correct copayment has been applied to the services that were provided. Pathology services fall within the outpatient diagnostic tests/lab services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for pathology services provided by a participating provider on March 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forpersonal care services (T1019) providedon October 28, 2019 through October 30, 2019.You asked the Plan to pay forthe personal care services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this service is non-covered under Medicare.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 code T1019 is not supported in the record.Specifically, per the physician fee schedule, CPT code T1019 has a status code of I. This means the CPT code T1019 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met.Therefore, we decided that the Plan does not have to pay forpersonal care services (T1019) provided on October 28, 2019 through October 30, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on February 27, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that the enrollee cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for ambulance services. The enrollee has been asked to pay a $225 copayment for ambulance services. Ambulance services falls within the ambulance services 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 copayment for ambulance services provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroffice visit services provided to the enrollee on January 6, 2020.You asked the Planto pay forthe services. You say that  The Plandenied your request. The Plansaysthe provider did not get an authorization for the services rendered.Medicarerules 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 Plandoes not haveto pay foroffice visit services provided to the enrollee on January 6, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 18, 2020.
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were provided while the enrollee was enrolled in Hospice.
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 the services provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided on January 13, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this services is included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for allfees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee no longer needs acute care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on December 11, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you have been seeing this provider for years and you never received a bill. The Plan denied your request. The Plan says providers that are not participating are allowed to bill the difference of their billed amount and the plan's allowed amount to the member.
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. Review of the file show that you received the dental services on December 11, 2019 from an out-of-network provider. Your EOC states, you'll save more when you receive care from one of the Plan's in-network dental providers. You can get care from an out-of-network dental provider but you may pay more. Therefore, we decided that the Plan does not have to pay for prophylaxis - adult (D1110) and periodic oral evaluation - established patient (D0120) provided on December 11, 2019 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSymbicort160-4.5 mcg inhaler for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.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 pre-approve Symbicort 160-4.5 mcg inhaler for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cardio MEMS system.You asked the Plan to pre-approve the requested services. You say that the Cardio MEMS is the enrollee's best option.The Plan denied your request. The Plan says the device has not been proven to improve the management of chronic heart failure compared to standard monitoring.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has a history of diabetes, hyperlipidemia, hypertension, sleep apnea, chronic kidney disease, non-ischemic cardiomyopathy, and Class III congestive heart failure with reduced LV ejection fraction requiring hospitalization. In this circumstance therapy change based on data obtained from a Cardio MEMS device has been demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the Cardio MEMS device is uncertain at this time, and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met, since the device is still considered experimental or investigational.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cardio MEMS system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram (77065) provided November 20, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that the copayment should be waived. The Plan denied your request. The Plan says the deductible was waived for the screening mammogram, however, the correct copayment was applied for the diagnostic mammogram.
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 Basic Imaging. You have been asked to pay a $10 copayment for the mammogram. The mammogram falls within the Basic Imaging 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 a diagnostic mammogram (77065) provided November 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room care (99283) provided January 13, 2020.
You asked the Plan to pay for Emergency Room care. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not submitted correctly.
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 code 99283 is not supported in the medical record. Specifically, the claim did not include a valid primary diagnosis code. Based on this information, we decided that Medicare rules for coverage of Emergency Room care have not been met. Therefore, we decided that the Plan does not have to pay for Emergency Room care (99283) provided January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. You say that this physician has treated you with chemotherapy and other therapies since you had breast cancer in August 2011. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 2, 2020.
You asked the Plan to pay for the 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. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on February 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on February 11, 2020 by an out of network (OON) provider.