Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 22, 2019 through December 27, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you believe you were cleared to go home sooner and it would have saved you a total of $550.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 shows that you were admitted on December 22, 2019 and discharged on December 27, 2019. You were asked to pay a $250 copayment per day from December 22, 2019 through December 26, 2019, days 1-5 of your inpatient stay. You were discharged on December 27, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-5. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care from December 22, 2019 through December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 24, 2020.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation submitted does not support a valid order for this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on February 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or
intolerance to zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Prolia. Our reviewer says that criteria
for the drug is not met. Our physician reviewer found the enrollee has a diagnosis of age-related osteoporosis
without current pathological fracture. The case file does not contain documentation of trial and failure of
Zoledronic acid. The documentation does not support that Zoledronic acid would likely be less effective, and/or
would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the x-ray provided on December 27, 2019 and the CT scan provided on January 16, 2020.You asked the Plan to waive the cost share for the x-ray and CT scan. You say that they did the wrong test twice. You say that you should be reimbursed.The Plan denied your request. The Plan says the cost share 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 2019 contract with the Plan clearly says that enrollees must pay a $10 copayment after the deductible is met for each basic imaging service. The enrollee's 2020 contract with the Plan clearly says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services.Until you have paid the deductible amount, you must paythe full cost of your covered services.The enrollee has been asked to pay a $10 copayment for the x-ray provided on December 27, 2019. The enrollee has also been asked to pay $197.19 toward the deductible for the CT scan provided on January 16, 2020. The x-ray and CT scan fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible in 2020applies to diagnostic imaging. This cost sharing is a contractual obligation that had not been met at the time the CT scan was received. 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 cost share for the x-ray provided on December 27, 2019 and the CT scan provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown on tooth 19 (D2740) provided January 16, 2020.
You asked the Plan to pay for the dental services. You say that you feel that crowns should be covered because
under most definitions of comprehensive dental care, previous experience tells you that crowns are covered
under that. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan does not cover for crowns, inlays and onlays under the plan benefits.
We looked at the file and the Plan's rules. Crowns are not listed as covered under the plan benefits. Based on
this information, we decided that the Plan's rules for coverage of the dental services have not been met.
Therefore, we decided that the Plan does not have to pay for crown on tooth 19 (D2740) provided January 16,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 19,
2019 to December 22, 2019.
You asked the Plan to pay for the self-administered drugs. You say that you were instructed by the Plan to file
a direct member reimbursement form. The Plan denied your request. The Plan says these drugs are self-administered
drugs and are not Part B covered.
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 pay for the self-administered drugs
provided from December 19, 2019 to December 22, 2019.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 28, 2019 through May 31, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 28, 2019 through May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening services (A9270) provided on February 28, 2020.You asked the Plan to pay for the screening services. You say that you would like reconsideration because these screenings were medically necessary due to your family history.The Plan denied your request. The Plan says you did not obtain a referral prior to the services being rendered.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 Plan contract states that for these services to be covered, you must get a referral from your physician, physician assistant, nurse practitioner or clinical nurse specialist. We looked at the file and the rules. Based on this information we have decided that criteria for coverage of the screening services have not been met. Specifically, the Plan requires a referral for these services. The record indicates that you did not obtain a referral prior to these services being rendered.Therefore, we decided that the Plan does not have to pay for the screening services (A9270) provided on February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid purchased on January 3, 2020 from a non-participating provider.You asked the Plan to pay for the hearing aid. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this claim would need to be sent to your supplemental hearing aid plan to be reimbursed.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.Review of the file show that you purchased the hearing aid on January 3, 2020 from a non-participating provider. According to plan benefits, hearing aids are not covered by Medicare. Through your supplemental hearing aid plan you may receive hearing aid services from any network hearing or hearing aid provider. Your Plan states this claim would need to be sent to your supplemental hearing aid plan to possibly be reimbursed. 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 hearing aid purchased on January 3, 2020 from a non-participating provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided from January 2, 2020 through February 28, 2020. You asked the Plan to waive the coinsurance for dialysis. You say that this is a treatment to keep you alive. You say that if it's a life threatening procedure the copayment should be waived. 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% coinsurance for Medicare-covered dialysis services within the service area when ordered by your PCP. You have been asked to pay $55.12, which is 20% of the allowed amount for each dialysis visit. The allowed amount is $275.60 (20% x $275.60 = $55.12). The total amount you owe is $1,267.76 ($55.12/visit x 23 visits = $1,267.76). Dialysis falls within the "Services to treat kidney disease" 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 dialysis provided from January 2, 2020 through February 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on February 3, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that if you were correctly diagnosed then the ambulance wouldn't have been necessary. You say that you don't feel responsible for the ambulance fee. 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 $125 for Medicare-covered ambulance services per day. You have been asked to pay a $125 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to a different hospital. 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 ambulance transport provided on February 3, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for eyelid repair (13151), excision (11442) and an office visit (99214) provided on August 12, 2019 and November 2, 2019.
You asked the Plan to pay for the eyelid repair, excision and office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the submitted records do 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 asked our coder 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 eyelid repair, excision and office visit. Our reviewer says that the records indicate that the services rendered on August 12, 2019 and November 2, 2019 are different. Our reviewer found the vital signs documented are different and the November 2, 2019 provider documented that the nasal skin ulcer on August 12, 2019 is similar. It is also noted that November 2, 2019 encounter notes an urgent visit. 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 eyelid repair, excision and office visit have been met. Therefore, we decided that the Plan has to pay for eyelid repair (13151), excision (11442) and an office visit (99214) provided on August 12, 2019 and November 2, 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 for the moderate sedation services rendered on November 4, 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 procedure code 99152 is not supported.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 99152 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes.We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the enrollee's level of consciousness and physiological status. 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 moderate sedation services rendered on November 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the MRI provided on December 27, 2019.
You asked the Plan to waive the coinsurance for the MRI. You submitted your bill for review. You say that you
provided proof of insurance. 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%
coinsurance for Medicare-covered complex diagnostic radiology services.
You have been asked to pay $127.23, which is 20% of the allowed amount for the MRI. The allowed amount is
$636.16 (20% x $636.16 = $127.23). The MRI 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 coinsurance for the MRI
provided on December 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound rendered on November 26, 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 procedure code 76641 is not supported.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 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete.We find that CPT code 76641 is not supported in the medical record. Specifically, the documentation supports that a limited breast ultrasound was performed and there is a more appropriate code for these services. 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 ultrasound rendered on November 26, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 18, 2019 to December 20, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that your emergency room copayment should be waived because you were admitted to the hospital. You say you received several procedures while in the hospital. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you were admitted to observation on December 18, 2019 and discharged on December 20, 2019.
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 emergency room visit provided on December 18, 2019 to December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient psychiatric stay provided from November 22, 2019 through November 24, 2019.
You asked the Plan to waive the copayment for the inpatient psychiatric stay. You say that you didn't meet the criteria for admission. You say that you shouldn't be charged. 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 $95 copayment per day, days 1 to 10 at an in-network inpatient hospital or inpatient psychiatric facility. You have been asked to pay a $190 copayment for the inpatient psychiatric stay. ($95/day x 2 days = $190). The inpatient psychiatric stay falls within the "Inpatient mental health care" benefit category. The records show that you were admitted for two days. 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 psychiatric stay provided from November 22, 2019 through November 24, 2019.
Appeal type: Lab
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 January 24, 2020.You asked the Plan to pay for the 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 for the medical services provided to the enrollee by an out-of-network provider on January 24, 2020.