Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordiagnostic imaging of the retina provided on August 12, 2019.You asked the Plan to waive the copayment fordiagnostic imaging of the retina. You say that you already paid $70 for the office visit and refraction and disagree with the additional charges.The Plan deniedyour 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 andcoinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for diagnostic procedures or tests. You have been asked to pay the allowed amount of $39.75, which is less than the $65 copayment for diagnostic imaging of the retina. Diagnostic imaging of the retina 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 fordiagnostic imaging of the retina provided on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for vacuum drainage collection unit and tubing kit (A7048) provided on November 12, 2019 and November 18, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you were advised your benefit for covered DME supplies is covered at 80% and you are responsible for 20%. 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 vacuum drainage collection unit and tubing kit provided on November 12, 2019 and November 18, 2019. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount for each date of service is $350. The total you owe per date of service is $70 ($350 x 20% = $70). The total you for the DME is $140. 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 vacuum drainage collection unit and tubing kit (A7048) provided on November 12, 2019 and November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee on October 16, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plansays they reviewed the call history associated with the member's account. The Plan states that during a phone call on October 28, 2019 the Plan customer service representative advised that the denial for inpatient on October 18, 2019 would not have additional cost-share due to readmission within the last 30 days. The Plan states the member does not have a copayment for the inpatient stay on October 18, 2019 andthe inpatient hospital stay for date of service October 16, 2019 was never discussed.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 the member received inpatient hospital care provided on October 16, 2019. The member is asked to pay a $375 copayment for the inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee on October 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on November 22, 2019.
You asked the Plan to waive the copayment for the breast ultrasound. You say that the ultrasound was done at the same time as your annual mammogram. You say that there should not be a copayment. 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 $250 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $75.55, which is less than the standard $250 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The breast ultrasound is considered a diagnostic 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 copayment for the breast ultrasound provided on November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 20, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for hearing services provided on September 16, 2019 and October 10, 2019.
You asked the Plan to waive the copayments for hearing services. You say that you received routine services and should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for hearing services. You received hearing services on September 16, 2019. The record shows that you received routine hearing services on August 15, 2019. Therefore, the hearing services received on September 16, 2019 are considered diagnostic and you are responsible to pay $10, which is less than the $35 copayment. You received hearing services on October 10, 2019. Therefore, you are responsible to pay the $35 copayment. The total amount you owe is: $45.00. You have been asked to pay the total copayment amount of $45.00 for hearing services. Hearing services fall within the hearing 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 hearing services provided on September 16, 2019 and October 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on March 27, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 to the enrollee on March 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick for the enrollee. You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered because it is a Part D drug. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel SureClick for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ER visit provided on October 8, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you disagree with the charges because you were only given a prescription for pain.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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER 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 in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ER visit provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for pain management services received from September 11, 2019 to October 28, 2019.
You asked the Plan to waive the copayments for the services. You say that you cannot afford all these excessive amounts. The Plan denied your request. The Plan says the copayments were applied correctly according to your benefits and the services rendered.
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 specialist office visits. You have been asked to pay a $35 copayment for the services. The services fall within the specialist 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 copayments for pain management services received from September 11, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that you would like to see if the doctor can prescribe
Zolpidem. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hepatitis A and B vaccine (90636) and typhoid vaccine (90691) provided on October 21, 2019. You asked the Plan to pay for the vaccines. You say that you would like reconsideration because you were traveling and at risk of contracting Hepatitis B. The Plan denied your request. The Plan says your request does not meet the Medicare rules because you received these vaccinations in preparation for travel and did not meet any of the Medicare defined high or intermediate risk groups. In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccines. Additionally, you do not meet any of the Medicare defined high or intermediate risk groups. Therefore, we decided that the Plan does not have to pay for the hepatitis A and B vaccine (90636) and typhoid vaccine (90691) provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visit provided on November 19, 2019.You asked the Plan to waive the deductible forthe office visit. You say that this was an in-network annual wellness visit. You say that it should be paid as in-network.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract says that the Plan has a combined deductible amount of $183 for covered Part B services from both in-network and out-of-network providers. Until you have paid the combined deductible amount, you must pay the full cost for covered Part B services from in-network or out-of-network providers.The item or service 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 your $183 deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on November 19, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe office visit provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for respiratory failure and failure to thrive. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee refused placement of a feeding tube. The documentation does not show that weaning was been attempted or failed. The long-term care plan and goals are unclear. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Resin Composite (D1999) provided on June 24, 2019.You asked the Plan to pay forthe Resin composite. You say that services were medically necessary.The Plan denied your request. The Plan says Resin Composites are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. Forthat 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 forResin Composite (D1999) provided on June 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 28, 2018 through January 1, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the surgery only took a few hours and you waited in the hospital for four days for you to have that done. 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 shows that you were admitted on December 28, 2018 and discharged on January 1, 2019. You were asked to pay a $225 copayment per day from December 28, 2018 through December 31, 2018, days 1-4 of your inpatient hospital care. You were discharged on January 1, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $225 copayment per day required for days 1-6 for in-network 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 inpatient hospital care from December 28, 2018 through January 1, 2019 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on October 8, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.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 99239 is not supported in the medical record. Current Procedural Terminology (CPT) code 99239 GC (1 Unit) remains not supported. The documentation submitted did not include a hospital discharge day management note with a documented duration of time of 31minutes or more for the billed date of service of October 08, 2019; therefore, the billed service cannot be verified. The submitted Discharge Summary is dated October 09, 2019. Of note, there is a daily progress note for the billed date October 08, 2019 for which there is a more appropriate Evaluation and Management CPT code that has to be billed. It is noted that multiple attempts were made to contact the provider for additional information. 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 forhospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora blood pressure monitor/blood pressure monitoring during an ambulance transport provided on October 21, 2019.You asked the Plan topay fora blood pressure monitor/blood pressure monitoringduring an ambulance transport. You say that the Plan should pay this claim.The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24 hours.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 A4670 is automatic bp monitor, dial.We find that CPT code A4670 is not supported in the medical record. Specifically, the enrollee did not receive a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately payable. Based on this information, we decided that Medicare rules for coverage of blood pressure monitoring during an ambulance transport have not been met.Therefore, we decided that the Plan does not have to pay for a blood pressure monitor/blood pressure monitoring during an ambulance transport provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out-of-network services. You say that you would like reconsideration because you confirmed with the provider that they were in-network prior to receiving services. The Plan denied your request. The Plan says you did not have out-of-network coverage for this service.
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 October 24, 2019 by an out of network (OON) provider.