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

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on July 1, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told the hospital would provide transportation. You say you were sent home by ambulance and are being billed for the ambulance ride. 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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance Service" 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 ride provided on July 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain or ceramic crown provided on August 19, 2019.You asked the Plan to pay forthe crown. You say that before this service was rendered, you checked with the Plan and were told that it would be covered. You also say that you cannot affordto pay this.The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances. The Plan also says that due to lack of payment, your supplemental Dental Platinum Rider was terminated on July 31, 2019.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 forthe porcelain or ceramic crown provided on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services provided by an in-network provider on September 26, 2018 and December 7, 2018.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2018 EOC benefits. The Plan states you will need to contact the provider directly to discuss any misapplied payments you may have made towards these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received x-rays provided by an in-network provider on September 26, 2018. You are asked to pay a $35 copayment for the x-rays. Furthermore, you received inpatient hospital care provided by an in-network provider on December 7, 2018. You are asked to pay a $225 copayment for the inpatient hospital care. 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 services provided by an in-network provider on September 26, 2018 and December 7, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 17, 2018 through October 19, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.ThePlan 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 forthe acute inpatient hospital care provided from October 17, 2018 through October 19, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the anesthesia services rendered to you on August 12, 2019.You asked the Plan to waive the cost sharing forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the cost sharing was applied correctly.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 $183yearly deductible for covered Part B services from both in-and out-of-network providers and a 20% coinsurance for in-network provider and professional services at an outpatient hospital or ambulatory surgical center.The item or service you asked the Plan to waive the cost sharing for falls within the in-network provider and professional services at an outpatient hospital or ambulatory surgical center benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $183 yearly deductible for covered Part B services from both in-and out-of-network providers. This cost sharing is a contractual obligation that had not been met at the time these services were received on August 12, 2019. The Plan applied the full $183 deductible for these services. Given that this did not cover the full cost of the services, you have also been asked to pay a 20% coinsurance for the remaining portion of the services, for a total of $34.12. The total amount you have been asked to pay for these services is $217.12.Therefore, we decided that the Plan does not have to waive the cost sharing forthe anesthesia services rendered to you on August 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services provided May 29, 2019 to May 31, 2019.You asked the Plan to pay forthe emergency room services. You say that services were medically necessary and properly billed.The Plan denied your request. The Plan says the codes at issue share bundled relationships with claim lines already paid and cannot be paid as separate line items.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 claim line items 1-25, 27, 30-47 and 52 represent bundled codes and cannot be paid as billed. These codes cannot be paid as separate line items. Lines 48-50 are marked with a "GY" modifier which denotes the claim cannot be paid by Medicare. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forEmergency Room Services provided May 29, 2019 to May 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the thoracic lumbar sacral orthosis (CPT Code L0486) provided on July 11, 2019.
You asked the Plan to waive the coinsurance for the orthosis. You say that you were not aware of the cost-share. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a thoracic lumbar sacral orthosis. Therefore, you are asked to pay 20% coinsurance for the orthosis. 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 thoracic lumbar sacral orthosis (CPT Code L0486) provided on July 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a shoulder-hand-wrist
orthosis (L3960) provided to the enrollee on September 2, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
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 a lumbar-sacral orthosis
(L0650) and a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on September 2, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have towaive the copayment forthe ED visit provided on September 27, 2019 through September 29, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that you were in the hospitalfor two nights as an inpatient.The Plandenied 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 Planclearly says that you must pay 20% coinsurance up to $80 max copaymentfor Medicare-covered emergency room visits.You have been asked to pay an $80 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were admitted to outpatient observation. 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 ED visit provided on September 27, 2019 through September 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection E2311 expandable controller E2377 and expandable controller harness E2313.
You asked the Plan to pre-approve electronic connection, expandable controller, and expandable controller harness. You say that all of the electronics requested are necessary to allow the enrollee to function while completing activities of daily living and allowing her to position herself to prevent pressure wounds. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary.
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 pre-approve electronic connection, expandable controller, and expandable controller harness. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require the E2311 controller as the enrollee's left upper limb strength is sufficient to operate the controls with their own included power options already included in the allowance for these options. There is no need to control the power options with a joystick, sip and puff or other non-proportional device, or to operate 3 or more actuators through the drive control. The enrollee does not require a separate display, an attendant control and other electronic devices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electronic connection, expandable controller, and expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection E2311 expandable controller E2377 and expandable controller harness E2313.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe discharge services provided on January 13, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.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 99239 is "Hospital discharge day management; more than 30 minutes".We find that CPT code 99239 is not supported in the medical record. Specifically, the records provided to not show that more than 30 minutes of hospital discharge day management services were provided on the date of service in question. 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 forthe discharge services provided on January 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 14,
2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that the provider relies on the facility staff to
obtained the necessary authorizations. The Plan denied your request. The Plan says authorization was not
obtained before the services were provided to the enrollee. 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 rendering facility is not a network
provider either. 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 subsequent nursing facility care provided on February 14, 2019 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 by out of network provider.
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 services were rendered by a non-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 for the medical services provided on September 3, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided from March 14,
2019 to April 19, 2019.
You asked the Plan to pay for the physician services. You say that the provider relies on the facility staff to
obtained the necessary authorizations. The Plan denied your request. The Plan says authorization was not
obtained before the services were provided to the enrollee. 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 requested provider in this case is not a network provider with the Plan. The rendering facility is not a
network provider either. 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 subsequent nursing facility care provided from March 14, 2019 to April 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on July 9, 2019.You asked the Plan to pay forthe 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 from the ordering physician.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 forthe drug testing services provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on June 11, 2019 by the out of network provider.
You asked the Plan to pay for the practitioner services. You say that the facility failed to obtain the necessary authorization for the enrollee. 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 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 for the rest home visit provided on June 11, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay fortheacute inpatient hospital care provided from March 8, 2019 through March 13, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that atthe 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 forthe acute inpatient hospital care provided from March 8, 2019 through March 13, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110), neuromuscular reeducation (97112) and therapeutic activities (97530) provided on May 2, 2019 through May 30, 2019.You asked the Plan to pay for the therapeutic services. You say that you would like reconsideration as the services provided were not related to the member's hospice diagnosis. The Plan denied your request. The Plan says the provider needs to bill Original Medicare, using the proper modifiers, for these services.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110), neuromuscular reeducation (97112) and therapeutic activities (97530) provided on May 2, 2019 through May 30, 2019.