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

We decided that the Plan does not have to waive the copayment for an emergency room visit, and an inpatient hospital stay provided by a participating provider on November 25, 2020, to November 27, 2020.
You asked the Plan to waive the copayment for an emergency room visit, and an inpatient hospital stay. You say that you do not agree with this denial. The Plan denied your request. The Plan says the correct copayments have 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 $90 copayment for emergency room care and a $345 copayment per day for day 1-5 for inpatient hospital care/in-network. You have been asked to pay a $90 copayment for an emergency room visit and a $345 copayment per day for day 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $780 ($90 + $690 ($345 x 2 days = $690) = $780). An emergency room visit falls within the emergency room care benefit category and an inpatient hospital stay falls within the inpatient hospital care/in-network 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. These services were not denied. The correct copayments have been applied to the services that were provided. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit, and an inpatient hospital stay provided by the hospital on November 25, 2020, to November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services.

You asked the Plan to pay for the dental services. You say that your dental benefit was not exhausted. The Plan denied your request. The Plan says you exhausted your annual dental benefit allowance prior to this date of 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 requested payment is in excess of those covered under this benefit. The Plan has provided evidence that you utilized the dental benefit exhausting the $500 dental allowance. Therefore, we decided that the Plan does not have to pay for the dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor and supplies (K0553).

You asked the Plan to pay for a therapeutic continuous glucose monitor and supplies. You say that the item provided was medically necessary. The Plan denied your request. The Plan says the services are not documented in the patient's record.

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 relevant medical records which support medical necessity for the supplies provided in this case. The medical records in this case are from greater than six months ago and therefore do not adequately support the medical necessity for the item in question. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous glucose monitor and supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered item or service, mobile based meditation education and guidance program (A9270).

You asked the Plan to pay for a mobile based meditation education and guidance program. You say that this program should be approved because it does fit with the wellness benefits in your plan. The Plan denied your request. The Plan says this item is not a covered benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only membership in a qualified health club or fitness facility. This benefit does not cover membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to, martial arts centers, gymnastics facilities, country clubs, sports clubs and social clubs; and for sports activities such as golf and tennis.

The Plan's rules for coverage of gym benefits have not been met because The Meditation Education and Guidance online program is not a covered benefit under the wellness allowance.. Therefore, we decided that the Plan does not have to pay for non-covered item or service, mobile based meditation education and guidance program (A9270).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests without a valid medical diagnosis related to the health of the enrollee is not a benefit.

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 file shows that Vitamin D and Vitamin B-12 testing was provided. The testing at issue was requested for screening purposes. There are no medical records to show that there were signs and symptoms to warrant the provided services. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test.

You asked the Plan to pay for the testing services. You say that you had yourself tested for peace of mind. The Plan denied your request. The Plan says the test was not rendered because of possible exposure or symptoms.

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 COVID-19 test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an attendant control.

You asked the Plan to pre-approve an attendant control. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested attendant control cannot be covered in addition to a beneficiary-operated joystick per Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that if an attendant control is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. 

We looked at the file and Medicare rules. An attendant control cannot be covered in addition to the  device control system already approved by the plan. Based on this information, we decided that Medicare rules for coverage of an attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve an attendant control.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visits with an out-of-network provider.

You asked the Plan to pre-approve out-of-network visits. You say that the Plan pulmonary doctors are not proactive about your treatment. You say that you are requesting to continue seeing this pulmonologist given your asthma challenges, the quality of treatment you require and being on a kidney transplant list. The Plan denied your request. The Plan says in-network providers are available.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 out-of-network visits. Our reviewer says that coverage criteria for an out of network specialist are not met. Our physician reviewer found that the enrollee has asthma, allergies, sinus disease, and chronic renal failure. In-network specialists are available to treat all of these conditions. Therefore, care by an out-of-network specialist is not considered 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 out-of-network visits have not been met. Therefore, we decided that the Plan does not have to pre-approve visits with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services could have been provided in-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.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99292) provided to the enrollee.

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 is an add-on code without the appropriate primary procedure.

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 99292 is "Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service."

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 supported by the medical records. Our coding reviewer found the documentation submitted was reviewed, and the billed code does not meet the criteria. CPT 99292 is an "add-on" code. A primary code is required when billing this code. It cannot be billed independently.

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 critical care services (CPT 99292) provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that the hospital kept you longer for more money. 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 $289 copayment for days 1-7 for inpatient hospital care.

You had an inpatient hospital stay. Therefore, you are responsible to pay a $289 copayment for days 1-4. $289 (copayment) x 4 (inpatient days) = $1,156.

You have been asked to pay the total copayment amount of $1,156 for an inpatient hospital stay. An inpatient hospital stay 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 an inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alternate vitamins that do not contain gelatin.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no substitutions allowed for over the counter products.

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. The plan does have a supplemental benefit for certain over-the-counter approved items. However, these alternative vitamins are not approved as an over-the-counter item. Therefore, we decided that the Plan does not have to pre-approve alternate vitamins that do not contain gelatin.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for services.

You asked the Plan to waive this copayment. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says the provider has confirmed you received this treatment, and this copayment applies.

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 $40 copayment for outpatient mental health care. 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 $40 copayment charged for services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits and an X-ray.

You asked the Plan to waive the copayments for specialist visits and an X-ray. You say that you were never charged in the past and disagree with the charges. 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 $40 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $15 copayment for X-rays.

You received a specialist visit and an X-ray. Therefore, you are responsible to pay the total amount of $55.

You have been asked to pay the total copayment amount of $55 for specialist visits and an X-ray. Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category. An X-ray 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 copayments for specialist visits and an X-ray.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cranial prosthesis (A9282).

You asked the Plan to pay for the cranial prosthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this is not a Medicare covered benefit.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the cranial prosthesis (A9282).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and a segmental pneumatic appliance (E0667) to be provided by an OON provider.

You asked the Plan to pre-approve a pneumatic compressor and a segmental pneumatic appliance. You say that the requested items are a necessity for you. The Plan denied your request. The Plan says rules for out of network services have not been met.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor (E0652) and a segmental pneumatic appliance (E0667) to be provided by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine PCR panel testing.

You asked the Plan to pay for lab test. You say that there is no evidence showing that this procedure code and diagnosis used are non-covered. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the standard of care for the evaluation of Dysuria is urinalysis with urine culture and sensitivity.

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 lab test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the standard of care for the evaluation of Dysuria is urinalysis with urine culture and sensitivity. This testing is considered unproven and not 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 lab test have not been met. Therefore, we decided that the Plan does not have to pay for urine PCR panel testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment for the office visit. You say that this was a pre-surgery exam, and the copayment should be removed. 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 $45 copayment for each specialist in-person office visit.

You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed in preparation for 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 copayment for the office visit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing.

You asked the Plan to pay for lab test. You say that you have no knowledge of the enrollee's coverage prior to
the specimen arrival and request that your lab not be penalized. The Plan denied your request. The Plan says
the denial of payment for this testing is correct, because the documentation submitted does not support the
Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken
in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting
- is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of
lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing.