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

We decided that the Plan does not have to pay forthe medical services provided on July 16, 2019 You asked the Plan to pay foroutpatient lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were self-directed.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 July 16, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee on June 23, 2019.You asked the Plan to pay forhome health services. You say that you were told this service did not require authorization.The Plan denied your request. The Plan says this service was not billed correctly.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was not billed with a valid Treatment Authorization Code.Therefore, we decided that the Plan does nothave to pay forthe home health services provided to the enrollee on June 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tetanus vaccine and administration (90715 and 90471) provided on September 5, 2019.You asked the Plan to pay for the tetanus vaccine. You say that you received the vaccine because it was recommended by a Plan nurse on previous visits. The Plandenied your request. The Plan says the vaccine was done as a routine encounter and is not covered under your Part B benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus vaccine and administration (90715 and 90471) provided on September 5, 2019. Benefits for the tetanus vaccine may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe ultrasound provided on May 28, 2019.You asked the Plan to reduce the copayment forthe ultrasound. You say that you should be charged a 20% coinsurance or $54.06 for the MRI performed. 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 inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each diagnostic procedure or test at a network outpatient facility. Youhave been asked to pay a $150 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows your received an ultrasound that scans blood flow.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 reduce the copayment forthe ultrasound provided on May 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from May 12, 2018 through June 12, 2018.
You asked the Plan to pay for inpatient mental health 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 psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as she did not have dangerousness to self or others. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided to the enrollee from May 12, 2018 through June 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran electroencephalogram (EEG) (95812) provided on October 25, 2018.You asked the Plan to pay foran EEG.. You say that this service was medically necessary.The Plan denied your request. The Plan says this service was not authorized.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 foran electroencephalogram (EEG) (95812) provided on October 25, 2018
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe positron emission tomography (PET)  on July 26, 2019.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 claim wasnot billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims for PET scans must be billed with the PI or PS modifier.We looked at the file and Medicare rules. The file shows that the claim for these services was not billed with either the required PI or PS modifier. 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 forthe positron emission tomography (PET) scan rendered  on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 7, 2019.You asked the Plan to pay foran office visit. You say that the office told you that they accepted your insurance.The Plan denied your request. The Plan says the member was self-referred. The Plan says that the member has no out-of-network coverage.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 August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient detox services provided on May 31, 2019 to June 7, 2019 by out of network provider, "the hospital". You asked the Plan to pay forthe inpatient detox services. You say that You say the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 inpatient detox services provided on May 31, 2019 to June 7, 2019 by out of network provider, "the hospital".
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on May 30, 2019.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 billed MUE exceeds the allowed limit.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 95941 is 0. You billed 1 unit of this code, exceeding the MUE. 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 forthe services rendered on May 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis.You asked the Plan to pre-approve the dialysis. The Plan denied your request. The Plan says the requested provider is not a network provider under the enrollee's Medicare Cost policy. In addition, the requested service, dialysis care, is available with designated Plan network dialysis providers.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve dialysis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 4, 2018 by out of network provider.You asked the Plan to pay fora follow-up office visit. You say that this was a follow-up appointment for wound care the member received as an inpatient.The Plan denied your request. The Plan says 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 forthe medical services providedon December 4, 2018 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ResMed AirMini CPAP machine purchased on May 23, 2019.You asked the Plan to reimburse you forthe ResMed AirMini CPAP machine. You say that you travel a lot and cannot take your bulky CPAP machine.The Plan denied your request. The Plan says the supplier is not a Medicare certified supplier.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to reimburse you forthe ResMed AirMini CPAP machine purchased on May 23, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora computed tomography (CT) scan and a lab test on July 22, 2019.You asked the Plan to waive the coinsurance forthe CT scan and the lab test. You say that you should not be responsible for these charges because you needed the services done because of a medical conditionThe Plan denied your request. ThePlan 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 35% coinsurance for out-of-network diagnostic radiology and CT scans and 35% coinsurance for out-of-network lab services. You have been asked to pay a total coinsurance amount of $134.53 for the CT scan and the lab test. The CT scan and the lab test fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityJuly 22, 2019CT scan$369.4935%$129.32July 22, 2019Lab test$14.8835%$5.21Total$134.53
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 forthe CT scan and the lab test provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visits provided from November 13, 2018 to August 20, 2019.You asked the Plan to waive the deductible forthe office visits. You say that the cost of each visit is $200 each month. You say you are trying to your money back. 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 $1,000 deductible that applies towards out-of-network office visits. The office visits you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards out-of-network office visits. This cost sharing is a contractual obligation that had not been met at the time the office visits were received on November 13, 2018 to August 20, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe office visits provided from November 13, 2018 to August 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit, ultrasound and bladder
assessment provided on July 16, 2019.
You asked the Plan to waive the copayments for the office visit, ultrasound and bladder assessment. You say
that the tests were important to find a treatment. You say that the Plan should pay for the diagnostic tests. The
Plan denied your request. The Plan says the copayments 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 $50
copayment for each covered specialist office visit, a $75 copayment for each covered x-ray in a provider's
office and a $70 copayment for each covered diagnostic procedure or test at a network doctor's office.
You have been asked to pay a total of $195 for the office visit, ultrasound and electronic bladder assessment.
Service Allowed Amount Standard Copayment Member Liability
Office Visit $120.92 $50 $50
Ultrasound $110.14 $75 $75
Bladder Assessment $72.64 $70 $70
TOTAL: $195
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The ultrasound and electronic bladder assessment fall within the "Outpatient diagnostic tests and
therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate
service. 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 office visit, ultrasound and bladder
assessment provided on July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reimburse you for the ostomy pouches purchased on July 23, 2019 from out of network provider.You asked the Plan to reimburse you forthe ostomy pouches. You say that you don't receive enough ostomy bags each month and because of your medical condition you ran out so you needed to get an emergency box of them.The Plan denied your request. The Plan says that the ostomy bags were purchased from a non-contracted supplier.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 reimburse you for care from out-of-network providers only in cases involving emergencies, urgently neededcare,and pre-approved care.The requested provider in this case is not a network provider with the Plan. However, there is no evidence that the network provider has a physical store to which you could have gone to purchase extra pouches. The documentation supports that this was a one-time urgent need due to an unforeseen increase in the amount of pouches needed. Therefore, we decided that the Plan has to reimburse you forthe ostomy pouches purchased on July 23, 2019 from out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on August 27, 2019.You asked the Plan to waive the copayment foran office visit. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for a primary care doctor visit. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on August 27, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for he root canal (D3320), and the whitening strips (D0001) provided on July 1, 2019.You asked the Plan to reimburse you forthe root canal or whitening strips. The Plan denied your request. The Plan says the root canal, and whitening strips are not listed as covered services.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 root canal, and whitening strips are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe root canal (D3320), and the whitening strips (D0001) provided on July 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on April 9, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code J3490 is not supported.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 J3490 is unclassified drugs.We find that CPT code J3490 is not supported in the medical record. Specifically, there is no documentation that an unclassified drug was administered. 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 forthe services rendered on April 9, 2019.