Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses and frames provided on October 21, 2019.
You asked the Plan to pay for the eyeglasses and frames. You say that you only go once a year. The Plan denied your request. The Plan says you exceeded your benefit allowance of 1 year and you are responsible for the denied amount of $100.
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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses and frames have not been met. Review of the file shows that you received eyeglasses on January 17, 2019 and the Plan paid $100 for this claim with no member liability. You also received glasses on October 21, 2019 and this claim is denied because you exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the eyeglasses and frames provided on October 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on July 30, 2019.You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are part of a bundled payment.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that train of four testing was completed. Train of four testing is considered a bundled procedure and payment for this service is included in payment for the already approved neuromonitoring services. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met.Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on July 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on October 13, 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 99232 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 99232 and 99233. Code 99232 is a column II code with a modifier indicator of 1 when billed with column I code 99233. Code 99232 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on October 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea wheelchair power seat elevation system (E2300).You asked the Plan to pre-approvea wheelchair power seat elevation system. You say that the requested item is necessary.The Plandenied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does nothave to pre-approvea wheelchair power seat elevation system (E2300).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management of an established patient, typically 25 minutes (99214) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided on October 8, 2019 by a non-contracted provider.You asked the Plan to pay for the services. You say that you have been going to this provider for over thirty-five (35) years and would like to continue seeing this provider.The Plan denied your request. The Plan says you do not have out-of-network benefits.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 evaluation and management of an established patient, typically 25 minutes (99214) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134) provided on October 8, 2019 by a non-contracted provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery provided on October 23, 2019.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you are appealing this amount. You say you only stayed in the hospital for one night. 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 $350 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center of hospital outpatient facility. You have been asked to pay a $350 copayment for the outpatient surgery. The outpatient surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery provided on October 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from November 12, 2019 through December 1, 2019.You asked the Plan to waive the copayment for the SNF stay. You say that proper authorization had not been secured. You say that you should not 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 $0 per day, days 1-20 and $167.50 per day, days 21-100 for each SNF stay.You have been asked to pay $1,507.50 for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay provided from November 12, 2019 through December 1, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services rendered to you on April 2, 2019.You asked the Plan to waive the copayment forthese services. You say that the procedure was not correctly performed.The Plan denied your request. The Plan says the copayment was 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 $300 copayment each time you are admitted to an acute care hospital. Review of the file shows that you received inpatient hospital services on April 2, 2019. You have been asked to pay a $300 copayment for these services. These services fall within the time you are admitted to an acute care hospital 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 forthe inpatienthospital services rendered to you on April 2, 2019.Your complaint about the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out-of-network (OON) provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says you must receive your care from a 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-approvephysical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea scooter.You asked the Plan to pre-approvethe scooter. You say that you have a back injury which makes it difficult to get around.The Plan denied your request. The Plan says the requested power operated vehicle is for outdoor use and is not covered by Medicare or considered medically reasonable and necessary.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The records provided show that the requested item is mostly to be used for long distances and community use.This means that the item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea scooter
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran Electrocardiogram (93010) provided by the Hospital on January 25, 2019.You asked the Plan to waive the copayment forthe Electrocardiogram. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was 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 paya $40 copayment for Diagnostic Tests. You have been asked to pay a $40 copayment for the Electrocardiogram. The Electrocardiogram falls within the Diagnostic Tests 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 foran Electrocardiogram (93010) provided by the Hospital on January 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 18, 2019 through August 19, 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 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show 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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 18, 2019 through August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forbitewing x-rays (D0274) and periodontal scaling and root planing(D4342, D4341m and D1330) provided on October 16, 2019.You asked the Plan to pay forbitewing x-rays and periodontal scaling and root planing. You say that this should be covered.The Plan denied your request. The Plan says these services processed correctly.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 excessof Medicare coverage, periodontal scaling and root planing is not among those covered under this benefit. The Plan covers one set of bitewings per plan year. The record shows that you received bitewings in 2019 prior to the date of service at issue.Therefore, we decided that the Plan does not have to pay forbitewing x-rays (D0274) and periodontal scaling and root planing (D4342, D4341m and D1330) provided on October 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a lithotripsy provided on November 7, 2019.
You asked the Plan to waive the copayment for a lithotripsy. You say that the machine broke during the first procedure and you feel that you should not be responsible for a second copayment. 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 $340 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $340 copayment for a lithotripsy. A lithotripsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a lithotripsy provided on November 7, 2019.
We note your complaint that the machine broke during the first procedure. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for interpretation of 3D Imaging (76376) performed September 19, 2019 by provider.You asked the Plan to pay for the imaging interpretation. You say that the service was medically necessary.The Plan denied your request. The Plan says coverage criteria was not met.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 76376 is not supported in the medical record. Specifically, the interpretation is not a separately billable service. Based on this information, we decided that Medicare rules for coverage of the imaging interpretation have not been met.Therefore, we decided that the Plan does not have to pay for interpretation of 3D Imaging (76376) performed September 19, 2019 by provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 95957 provided on October 14, 2019.You asked the Plan to pay forCPT code 95957. You say that you would like the Plan to reconsider their denial of payment.ThePlan denied your request. The Plan says the medical records do not support the billing of CPT code 95957.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 95957 is Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis).We find that CPT code 95957 is not supported in the medical record. Specifically, the documentation provided does not include documentation of digital analysis of EEG on October 14, 2019. Based on this information, we decided that Medicare rules for coverage of CPT code 95957 have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 95957 provided on October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forCritical Care Services (99291) provided May 9, 2019 to May 12, 2019.You asked the Plan to pay forthe critical care services. You say that services were medically necessary and correctly billed.The Plan denied your request. The Plan says the 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.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 medical record. Specifically, the records do not show how much time was spent providing the Critical Care services. 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 forCritical Care Services (99291) provided May 9, 2019 to May12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens (V2781) provided on October 31, 2019 by an out-of-network provider.You asked the Plan to pay for the progressive lens. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this vision service is not covered by this medical plan. The Plan states if you have vision coverage, your provider should submit to that vision Plan for coverage determination.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Review of the file show that you received progressive lens (V2781) provided on October 31, 2019 by an out-of-network provider. Your EOC clearly states, covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses, or anti-reflective coating). Therefore, the progressive lenses are not covered.Therefore, we decided that the Plan does not have to pay for progressive lens (V2781) provided on October 31, 2019 by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora clinic visit (99222, G0463, 99283, 93000) provided on July 30, 2019.You asked the Plan to pay fora clinic visit. You say that these were emergency services.The Plan denied your request. The Plan says medical records were not received with your reimbursement request.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 todetermine whether payment is due and the amount of payment.We looked at the file and Medicare rules. No medical records were submitted for the date of service at issue. Without this information, medical necessity cannot be established. Based on this information, we decided that Medicare rules for coverage of a clinic visit have not been met.Therefore, we decided that the Plan does not have to pay fora clinic visit (99222, G0463, 99283, 93000) provided on July 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the physical therapy visits provided from September 16, 2019 to October 28, 2019.You asked the Plan to waive the cost share for the physical therapy visits. You say that the services were approved and you were told you would not have a copayment for the services.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. Your contract with the Plan says that there is a $200 deductible that applies to in-network physical therapy visits and a $30 copayment for each in-network Medicare-covered physical therapy visit after you have paid the annual deductible. The physical therapy visits you asked the Plan to waive the cost share for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 deductible that applies towards in-network physical therapy visits and a $30 copayment for each in-network Medicare-covered physical therapy visit after you have paid the annual deductible. This cost sharing is a contractual obligation that had not been met at the time the physical therapy visits was received on September 16, 2019 to October 28, 2019.Therefore, we decided that the Plan does not have to waive the cost share for the physical therapy visits provided from September 16, 2019 to October 28, 2019.