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

We decided that the Plan does not have to pay for the medical services provided on July 11, 2019 by out of network provider.You asked the Plan to pay for x-rays. You say that no authorization should have been needed for the service in question.The Plan denied your request. The Plan says no prior authorization was obtained for the service in question. The Plan says that the referring provider is also out-of-network.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 July 11, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography coded 93312, the doppler echocardiography coded 93320, and the doppler echocardiography color flow velocity mapping coded 93325 provided on May 30, 2019.
You asked the Plan to pay for the echocardiography, the doppler echocardiography, and the doppler echocardiography color flow velocity mapping. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 93312 is Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report
The CPT Code Manual definition of code 93320 is Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete.
The CPT Code Manual definition of code 93325 is Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) We find that CPT code 93312, 93320, and 93325 are not supported in the medical record. Specifically, the documentation does not support that code 93312 is separate from code 00563 also billed on the claim. The probe replacement may not be billed separately. Also, the documentation received does not support the add on codes of 93320 and 93325 as they were billed without required primary codes. Based on this information, we decided that Medicare rules for coverage of the echocardiography, the doppler echocardiography, and the doppler echocardiography color flow velocity mapping have not been met. Therefore, we decided that the Plan does not have to pay for the echocardiography coded 93312, the doppler echocardiography coded 93320, and the doppler echocardiography color flow velocity mapping coded 93325 provided on May 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (CPT 99214) provided to the enrollee on June 18, 2019.
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The Plan says on the corrected claim, the provider added a modifier -79, which is not a valid modifier.
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 99214 is not supported in the medical record. Specifically, this code was not billed with the appropriate modifier in this case. Based on this information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (CPT 99214) provided to the enrollee on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on August 6, 2019 by the out of
network provider.
You asked the Plan to pay for the practitioner services. You say that the enrollee is home bound. You also say
that he would not receive medical care if you did not see him in his assisted living facility. 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 in nature.
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 referring provider 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 rest home visit provided on August 6, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora magnetic resonance imaging (MRI) of the brain (70551) provided on June 7, 2019.You asked the Plan to waive the copayment for the MRI of the brain. You say that you were told your copayment would be $161.36 at the time of service.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment for diagnostic radiology services. You have been asked to pay $38.64 for the MRI of the brain. $200 -$161.36 (amount you already paid) = $38.64. An MRI of the brain falls within the 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 copayment fora magnetic resonance imaging (MRI) of the brain (70551) provided on June 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for negative pressure wound therapy (E2402) provided from May 10, 2019 through June 6, 2019.
You asked the Plan to waive the coinsurance for negative pressure wound therapy. You say that you want the copay waived because you only make $900 on social security each month and cannot afford it. You were also told by the healthcare coordinator that this would be covered in full. The Plan denied your request. The Plan says durable medical equipment (DME) has a 20% coinsurance.
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 for durable medical equipment (DME). You have been asked to pay a 20% coinsurance for negative pressure wound therapy. This service falls within the durable medical equipment (DME) benefit category. The allowable amount $2,065.00 x 20% = $413 x 2 dates of service = $826). 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 negative pressure wound therapy (E2402) provided from May 10, 2019 through June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (G0283) you received from June 18, 2019, to July 15, 2019.You asked the Plan to pay for the chiropractic services. You say that you cannot pay for the services.The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (G0283) you received from June 18, 2019, to July 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method (CPT Code 95937) provided to the enrollee on May 21, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The enrollee's condition doesn't meet the rules for approval because the medical records from the surgery do not demonstrate that the enrollee has symptoms of weakness due to diseases of the neuromuscular junction such as myasthenia gravis, Lambert Eaton myasthenic syndrome (LEMS) or botulinum toxicity.Therefore, we decided that the Plan does not have to pay forneuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method (CPT Code 95937) provided to the enrollee on May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forextended ophthalmoscopy with retinal drawing and office visit provided on August 28, 2019.You asked the Plan to waive the copayments forophthalmoscopy and office visit. You say that this was a diabetic exam and should have a $0 copayment.The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.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 $75 copayment for ophthalmoscopy and $35 copayment for eye exam from an in-network provider. You had already received the once yearly diabetic eye exam on April 4, 2019 with $0 copayment, therefore that benefit was exhausted on this date of service. For the ophthalmoscopy procedures you have been asked to pay the allowed amount of $54.10, which is less than the $75 copayment for in-network diagnostic procedures. For the eye exam office visit you have been asked to pay $20.90, which is less than the $35 copayment for an in-network eye exam. Therefore, your total copayment obligation is $75.You have been asked to pay less than $75 copayment for ophthalmoscopy and less than $35 copayment for eye exam. Ophthalmoscopy and office visit fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Vision Care" benefit categories. 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 forextended ophthalmoscopy with retinal drawing and office visit provided  on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 00750 provided on November 28, 2018.
You asked the Plan to pay for CPT code 00750. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says that when anesthesia services are performed, physicians must report the appropriate anesthesia modifier to denote whether the service was personally performed, medically directed, or medically supervised. The file shows the claim was submitted without an appropriate anesthesia modifier. Based on this information, we decided that Medicare rules for coverage of CPT code 00750 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 00750 provided on November 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of a foreign body from the foot provided on May 2, 2019 by the out ofnetwork provider.You asked the Plan to pay forthe outpatient surgical services. You say that you were unaware that the provider was out of network with the enrollee's Plan.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services were not urgent or emergent. The Plan also saysMedicare 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 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 removal of a foreign body from the foot provided on May 2, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient mental health care provided from December 1, 2018 through December 10, 2018.You asked the Plan to waive the copayment forinpatient mental health care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 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 inpatient mental health care from December 1, 2018 through December 10, 2018. You are asked to pay a $900 copayment for the admission. 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 forinpatient mental health care provided from December 1, 2018 through December 10, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSNFcare provided to the enrollee from June 30, 2019 through July 29, 2019.You asked the Plan to pay forSNF 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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursingor therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from June 30, 2019 through July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe office visits, fluoroscopic guidance and Part B drugs provided on July 25, 2019, July 31, 2019 and August 7, 2019.You asked the Plan to waivethe cost share forthe office visits, fluoroscopic guidance and Part B drugs. You say that you were informed the treatment would be done in three sessions instead of one. You say that one copayment should cover all three appointments.The Plan denied your request. The Plan says the cost share 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 $40 for each Medicare-covered visit with an in-network specialist, $30 per day, per provider, for in-network diagnostic procedures and tests and 20% for each Medicare-covered Part B drug. You have been askedto pay a total of $549.71 for the office visits, fluoroscopic guidanceand Part B drugs.Date of ServiceServiceAllowed AmountStandard CostMember LiabilityJuly 25, 2019Office Visit$72.30$40$40July 25, 2019Fluoroscopic Guidance$96.44$30$30July 25, 2019Hyaluronan Injection$42520%$85July 25, 2019Methylprednisolone Injection$6.2420%$1.25July 25, 2019Fentanyl Citrate Injection$0.8120%$0.16July 25, 2019Midazolam Hydrochloride Injection$0.3320%$0.07July 31, 2019Office Visit$72.30$40$40July 31, 2019Fluoroscopic Guidance$96.44$30$30July 31, 2019Hyaluronan Injection$732.4820%$146.50August 7, 2019Fluoroscopic Guidance$96.44$30$30August 7, 2019Hyaluronan Injection$732.4820%$146.50August 7, 2019Fentanyl Citrate Injection$0.8120%$0.16August 7, 2019Midazolam Hydrochloride Injection$0.3320%$0.07TOTAL:$549.71The office visitsfall within the "Physician/Practitioner services, including doctor's office visits" benefit category. Fluoroscopic guidance falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefitcategory. The Part B drugs fall within the "Medicare Part B prescription drugs" benefit category.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost share forthe office visits, fluoroscopic guidance and Part B drugs provided on July 25, 2019, July 31, 2019 and August 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided from May 15, 2019 through July 17, 2019.You asked the Plan to waive the copayment forSNF care. You say that you are appealing your cost-share responsibility for the services you received.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). You were admitted for SNF care on May 15, 2019 and discharged on July 17, 2019. Therefore, you are asked to paya $25copayment per day for days 21 -100 for Medicare-covered stays at a SNF. 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 forSNFcare provided from May 15, 2019 through July 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit provided by "the hospital"  on August 12, 2019.You asked the Plan to waive the copayment foran emergency room visit. You say that the hospital should have taken an x-ray of your ribs when you went to the ER the first time.The Plan denied your request. The Plan says the correct copayment has been 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 pay a $120 copayment for emergency care. You have been asked to pay a $120 copayment for an emergency room visit. Anemergency room visit falls within the emergency 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 inthe Plan.Therefore, we decided that the Plan does not have to waive the copayment foran emergency room visit provided by "the hospital" on August 12, 2019.We note your complaint about not having all the x-rays you needed in yourfirst emergency room visit. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on May 24, 2019.You asked the Plan to waive the copayment for an endoscopy. You say that you do not know why you are being charged so much when your last endoscopy was under $100. You say that you would like to see this adjusted.The Plan denied your request. The Plan says the correct copayment has been 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 pay a $300 copayment for outpatient surgery/in-network. You have been asked to pay a $300 copayment for an endoscopy. The correct copayment has been applied to the surgery that was provided. An endoscopy falls within the outpatient surgery/in-network 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 an outpatient surgery provided on May 24, 2019.