Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on June 26, 2019 by out of network (OON) provider.
You asked the Plan to pay for the OON lab testing. You say that this testing was medically necessary and should be approved. The Plan denied your request. The Plan says the enrollee is required to receive care from network providers. This non-emergency lab test was provided OON without authorization. This denial of payment is correct.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the lab testing provided on June 26, 2019 by out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchemotherapy administration (96413 and 96417) provided on July 22, 2019.You asked the Plan to pay forchemotherapy administration. You say that these codes should be paid.The Plan denied your request. The Plan says these codes are not supported by the medical record.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 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour,single or initial substance/drug, and the definition of 96417 is chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure).We find that CPT code 96413 is not supported in the medical record. Specifically, these are time-based codes and the documentation does not include the time spent on these services. Based on this information, we decided that Medicare rules for coverage of chemotherapy administration have not been met.Therefore, we decided that the Plan does not have to pay forchemotherapy administration (96413 and 96417) provided on July 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound behind the abdominal cavity (76775) provided on June 7, 2019.You asked the Plan to waive the copayment for an ultrasound. You say that you state that you were advised to appeal by a plan representative and that you were just recently informed about the claim being processed and does not understand why the plan only paid $14.02.The Plan denied your request. The Plan says outpatient radiological diagnostic services have a $100 copayment. The Plan also says diagnostic radiology services require specialized equipment beyond standard x-ray equipment and must be performed by specially trained or certified personnel. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies).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 $100 copayment for outpatient radiological diagnostic services. You have been asked to pay a $100 copayment for an ultrasound. This service falls within the outpatient radiological diagnostic services benefit category. These types of ultrasounds require specialized equipment and need to be performed by specially trained personnel.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 ultrasound behind the abdominal cavity (76775) provided on June 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to from November 4, 2017 to November 29, 2017.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 the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Form CMS-1450, also known as the UB-04 form, is a uniform institutional provider bill used in billing multiple third party payers.We looked at the file and Medicare rules. The file shows that the claims were not billed on the required UB-04 form. 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 home health services rendered to from November 4, 2017 to November 29, 2017.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for pulmonary stress testing provided on August 9, 2019.
You asked the Plan to waive the copayment for pulmonary stress testing. You say that you were informed you do not qualify for portable oxygen. You say that you refuse to pay the bill. The Plan denied your request. The Plan says the $10 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 $10 copayment for non-radiological diagnostic services at any other settings. You have been asked to pay a $10 copayment for pulmonary stress testing. Pulmonary stress testing 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 copayment for pulmonary stress testing provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 22, 2019 by out ofnetwork provider, "the doctor".You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe medical services provided on March 22, 2019 by out of network provider, "the doctor".
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 15, 2019.You asked the Plan to waive the copayment for laboratory services. You say that you should not owe a copayment for primary care provider visits.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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 copayment for laboratory services provided on August 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe colonoscopy, as well as ablation, removal, and biopsy of tumor, polyp, or leision provided on August 6, 2019 by an out of network provider.You asked the Plan to pay forthe surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or 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 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 forthe colonoscopy, as well as ablation, removal, and biopsy of tumor, polyp, or leision provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on May 29, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the physician order was invalid because it did not include the specifications of the billed orthosis.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 shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. There is insufficient detail on the specifications for the billed orthosis, so the billed code cannot be verified.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on April 7, 2019.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 any and all codes on this claim are denied, and in addition, previous payments to these providers for this member are subject to recoupment.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for lab services provided on April 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided July 31, 2019 August 7, 2019.You asked the Plan to pay for the inpatient hospital services. You say that the inpatient hospital admission was medically necessary and reasonable as evidenced by the condition of the enrollee and services provided.The Plan denied your request. The Plan says the claim does not meet pre admission bundling requirements.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.The provider is required to submit pre admission services on the inpatient facility claim. But they are only allowed three (3) days prior to and including the dateof admission to have these preadmission services completed. If the provider has preadmission services performed more than three (3) days prior, the claim will deny and the provider would need to submit a corrected claim in order to receive payment. Per CMS, providers can bill preadmission services on their inpatient claim as long as they are within 3 days of Admit Date. However, when the provider changed the from date of service on the Corrected Claim, it put the preadmission services date outside that 72hours; therefore, the claim deny with the 1180 denial -does not meet preadmission bundling requirements. Based on the claim submitted, Medicare billing criteria have not, we decided that Medicare rules for coverage of the inpatient hospital services have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided July 31, 2019 August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient office visits provided from August 14, 2019 to August 15, 2019.
You asked the Plan to waive the copayments for the outpatient office visits. You say that you were not told there would be extra charges for the physician visits during your observation. 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 $35 copayment for each specialist visit, including outpatient clinic visits. You have been asked to pay a $35 copayment for each of the outpatient office visits. The outpatient office visits fall within the "Outpatient hospital 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 copayments for the outpatient office visits provided from August 14, 2019 to August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four Testing (95999) provided December 5, 2018.You asked the Plan to pay for the service. You say that the services were medically necessary and properly billed.The Plan denied your request. The Plan says the train of four testing is bundled in the already paid neuromonitoring codes.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, we have confirmed that code has a bundled relationship with the Neuromonitoring codes already paid and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for the service (95999) provided December 5, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by the practitioner from November 30, 2019 to June 7, 2019.You asked the Plan to pay for the dental services. You say that you need these services done because you are trying to prevent health issues that result from poor teeth. You say the insurance should pay.The Plan denied your request. The Plan says the services are not covered benefits.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 dental services are not among those covered under this benefit.Please note, the resin-based composite is a covered service and the cost-share was applied appropriately. See chart below. Therefore, we decided that the Plan does not have to pay forthe dental services provided by the practitioner from November 30, 2019 to June 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on August 26, 2019.You asked the Plan to waive the copayment for wound debridement. You say that you only had skin removed from your toe.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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for wound debridement. Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Wound debridement is considered 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 wound debridement provided on August 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the breast ultrasound rendered to you by Newton Wellesley Hospital on September 10, 2019.You asked the Plan to waive the coinsurance for these services. You say that you don't understand the charges.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance up to a maximum of $75 per day for Medicare-covered diagnostic radiology services. Review of the file shows that you received a breast ultrasound on September 10, 2019. You have been asked to pay a 20% coinsurance up to a maximum of $75 per day for these services, for a total of $15.11. These services fall within the Medicare-covered diagnostic radiology 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 coinsurance for the breast ultrasound rendered to you on September 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits provided from May 29, 2019 and July 10, 2019 by out of network provider. You asked the Plan to pay for the home visits. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services the enrollee received are not a covered benefit when provided by an out-of-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the home visits provided from May 29, 2019 and July 10, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora complete series of radiographic images received on September 5, 2019.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 the frequency limit has been exceeded for this 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. The Plan covers one complete series of radiographic images every five years.A review of the file shows that this same service was received less than five years ago, on August 20, 2019. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay fora complete series of radiographic images received on September 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries from July 24, 2019 to August 14, 2019.
You asked the Plan to waive the copayments for the cataract surgeries. You say that you want to appeal the copayments. 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 $300 copayment for outpatient surgery services. You have been asked to pay a $300 copayment for each of the cataract surgeries. The cataract surgeries fall 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 copayments for the cataract surgeries from July 24, 2019 to August 14, 2019.
Your complaint about the unfair upgrade charge for the lens 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.