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

We decided that the Plan does not have to pay for physician services and lab work provided on June 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services and lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that no prior authorization was obtained. The Plan says these services were non-emergent.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 physician services and lab work provided on June 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a prosthetic. You say that receiving a prosthetic is the last part of the services to be provided with you. The Plan denied your request. The Plan says there are in-network providers available for this service.
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 prosthetic to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 5, 2019.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that the office representative checked with your plan and told you that you were covered for one cleaning and one exam. You also say that you did not receive x-rays while you were at the dentist. The Plan denied your request. The Plan says this service is not covered by the Plan.
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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided December 5, 2019.You asked the Plan to pay for the dental services. You say that you had an appointment in May for the same procedure as the procedure done in December . The plan paid more for the procedures done in May and you do not understand why there is a difference.The Plan denied your request. The Plan says this claim was processed correctly with the out of network fee schedule.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 if you see a non-participating dentist for covered dental services you may pay more.You have been asked to pay $107 for the dental services. The services fall within the Dental 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 pay for the dental services provided December 5, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit provided on July 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for an outpatient clinic visit. You say that you do not agree with this denial. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 for an outpatient clinic visit provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 12, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay for the lab services provided on March 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you travelled to your daughter's house in California after flying from Pennsylvania. You say that you passed out several times and your daughter called for an ambulance. The ambulance attendants took your vitals and told you that they appeared to be normal. You say that you declined transportation to the hospital, however during the rest of the week you began to feel very weak and had to go to the emergency room. You stated that it was determined that you had strep throat. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 25, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis RT, LT (L1833) and sleeves LT. RT (L2397) provided October 31, 2019. You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records provided do not support the service billed.
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 the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case there is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis RT, LT (L1833) and sleeves LT. RT (L2397) provided October 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says that the claim processed 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 $265
copayment per date of service regardless of the number of ground ambulance trips.
You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls
within the ground ambulance trips 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 ambulance transport provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291).
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records submitted upon appeal appear to have been altered to include the critical care time.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the altered critical care note that was submitted upon appeal does not meet criteria for accepted Recordkeeping Principles. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for admission to an inpatient hospital.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that the medical necessity was not established by the clinical records.
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 has determined 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 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 admission to an inpatient hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the debridement services you received from December 3, 2019 to December 31, 2019.You asked the Plan to waive the copays for the services provided. You say that no surgery was performed.The Plan denied your request. The Plan says cost-sharing is a contractual obligation and cannot be waived.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 $225copay for outpatient surgery. The file shows that you received debridement services on December 3, 10, and 31, 2019. The debridement services are considered surgical services. You have been asked to pay a $225 copay for each date of service. The services fall within the outpatient surgery 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 copays for the debridement services you received from December 3, 2019 to December 31, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye exam, frames and lenses provided January 18, 2020.You asked the Plan to pay for the vision services. You say that a plan representative had told you that this service would be covered with this provider. You have had a lot of medical issues the past 2 years so any help with these bills is appreciated.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.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 covers these services when provided by an in-network provider.We looked at the file and the Plan's rules. Services provided out of network is not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay for eye exam, frames and lenses provided January 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture provided November 25, 2019.
You asked the Plan to pay for the dental services. You say that you request reconsideration because you did not know there was a time frame for dental work. You had to do the dental over again because the provider did lousy work which you are still paying for. The Plan denied your request. The Plan says this request exceeds the 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. This service is allowed once every 60 months (5 years). The records show this service was provided December 31, 2015. Therefore this service would not be available for coverage until December 31, 2020. 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 upper partial denture provided November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing test provided.
You asked the Plan to waive the copayment for a hearing test. You say that you already paid your copayment and disagree with the additional 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 $45 copayment for hearing services. You have been asked to pay the allowed amount of $37.91, which is less than the $45 copayment for a hearing test. A hearing test falls within the hearing 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 a hearing test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a specialist visit provided.
You asked the Plan to waive the deductible for a specialist visit. You say that you want to know if the charges are correct. 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. Your contract with the Plan says that there is a $245 deductible for physician/practitioner services, including doctor's office visits. You had a specialist visit. The record shows that you had paid $0 toward the $245 deductible prior to receiving the service. Therefore, you are responsible to pay the allowed amount of $216.42. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $245 deductible for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received. Therefore, we decided that the Plan does not have to waive the deductible for a specialist visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression arm sleeve identified with code S8424.
You asked the Plan to pre-approve the compression arm sleeve. You say that at first the sleeves were covered
but when you turned 65 they were no longer covered. Without the sleeves you have flare ups of lymphedema.
The Plan denied your request. The Plan says S codes may not be used to bill services paid under any Medicare
payment system. Medicare does not reimburse for services under S codes.
The Plan must follow Medicare rules. The rules say that compression stockings described by code S8424 are
non-covered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression arm
sleeve identified with code S8424.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43239) provided on October 30, 2019.
You asked the Plan to pay for an esophagogastroduodenoscopy. You say that this should be reviewed for payment. The Plan denied your request. The Plan says this code is not documented in the records.
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 43239 is esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple. We find that CPT code 43239 is not supported in the medical record. Specifically, the medical records for this date of service only document that a colonoscopy was performed. There is no documentation for an esophagogastroduodenoscopy. Based on this information, we decided that Medicare rules for coverage of an esophagogastroduodenoscopy have not been met. Therefore, we decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43239) provided on October 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 9, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection provided.
You asked the Plan to waive the coinsurance for the injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an injection on the date of service at issue in this appeal. The Plan says the correct coinsurance as applied per your contract with the Plan.
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 15% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an injection on September 25, 2019. You have been asked to pay a 15% coinsurance for the injection, totaling $396. The injection falls within the Medicare Part B prescription drugs 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 injection provided.