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

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on December 26, 2019.You asked the Plan to pay for the subsequent nursing facility care. You say that the services were required and provided to the enrollee.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.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 the subsequent nursing facility care provided on December 26, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit and nasal/sinus endoscopy with biopsy, polypectomy or debridement provided on December 18, 2019.

You asked the Plan to pay for the outpatient office visit and nasal/sinus endoscopy with biopsy, polypectomy or debridement. You say that you were on hospice at the time of these services, but this diagnosis is unrelated to your hospice diagnosis. The Plan denied your request. The Plan says that Original Medicare is responsible for the hospice services that are related or unrelated to your hospice diagnosis.

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 the outpatient office visit and nasal/sinus endoscopy with biopsy, polypectomy or debridement provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274), first intraoral periapical x-ray (D0220), and additional intraoral periapical x-ray (D0230) provided on January 8, 2020.
You asked the Plan to pay for the bitewings and intraoral periapical x-rays. The Plan denied your request. The Plan says these services are not covered by your health plan or Medicare.
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 for the bitewings (D0274), first intraoral periapical x-ray (D0220), and additional intraoral periapical x-ray (D0230) provided on January 8, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ECG provided on December 7, 2019.You asked the Plan to pay forthe ECG. You say that you were on hospice at the time of thisservice, but this diagnosis is unrelated to your hospice diagnosis.The Plan denied your request. The Plan says that Original Medicare is responsible for the hospice services that are related or unrelated to your hospice diagnosis.Medicare rules saythat 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 forthe ECG provided on December 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 20, 2019.
You asked the Plan to pay for the 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 for the medical services provided to the enrollee by an out-of-network provider on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided from June 26, 2019 to June 29, 2019
You asked the Plan to pay for critical care. You say that the services were provided. The Plan denied your request. The Plan says the documentation does not support this code.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records submitted do not document the time spent on this service on any of the dates of service at issue. Without this information, it cannot be verified that this code was correctly billed for 30-74 minutes. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided from June 26, 2019 to June 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on October 15, 2019. You asked the Plan to pay for the ECG. You say that you were not aware that prior authorization was needed. The Plan denied your request. The Plan says prior authorization is required. 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 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 for an ECG provided on October 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99283 provided on
September 19, 2019.
You asked the Plan to pay for the emergency department visit. 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 separately
payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99283
for the emergency department visit has a bundled relationship with code 99285 and cannot be paid as billed.
This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit
coded 99283 provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided on January 13, 2020.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that this modality is allowed per CMS guidelines. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
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 for extraspinal chiropractic manipulation (98943) provided on January 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on January 13, 2020.You asked the Plan to waive the copayment forthe colonoscopy. You say that there should be no cost for a colonoscopy screening.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 $250 copaymentfor each Medicare-covered outpatient surgery or procedure at an in-network outpatient hospital facility or ambulatory surgical center. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery,including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the colonoscopy was performed due to diagnoses of anemia and hemorrhoids which makes the colonoscopy diagnostic in nature.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 thecopayment forthe colonoscopy provided on January 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on October 16, 2018.
You asked the Plan to pay for the ambulance transport. You say that you would like the Plan to reconsider payment. The Plan denied your request. The Plan says that this claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the ambulance transport was not filed until December 21, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on October 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics. You asked the Plan to pay for foot orthotics. You say that the orthotic is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on January 24, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should only have a $5 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 a $40 copayment for covered services to a medical facility or urgent care center per visit. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 for the urgent care visit provided on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe athletic club membership fee provided from January 1, 2019 to December 31, 2019.You asked the Plan to pay forthe athletic club membership fee. The Plan denied your request. The Plan says that this is not covered by the Plan.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when you go to a Silver&Fit fitness club, YMCA or exercise center near you that takes part in the program..The Plan's rules for coverage of gym benefits have not been met because you did not go to a facility that takes part in the program.Therefore, we decided that the Plan does not have to pay forthe athletic club membership fee provided from January 1, 2019 to December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe walker and seat attachment provided on December 31, 2019.You asked the Plan to waive the coinsurance forthe walker and seat attachment. You say that you were informed of the out-of-pocket expense. You say that you couldn't make an informed decision regarding your care.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered durable medical equipment item. You have been asked to pay a total of $23.47 for the walker and seat attachment. The walker and seat attachment fall within the "Durable medical equipment (DME) and related 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 coinsurance forthe walker and seat attachment provided on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210)and limited oral exam (D0140) provided January 13, 2020.
You asked the Plan to pay for the dental services. You say that your dentist was denied payment, therefore you paid the whole bill. The Plan denied your request. The Plan says the services are not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract says that any service not listed is not covered. The contract also says that services provided by out-of-network providers are not covered. 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 for the surgical extraction (D7210)and limited oral exam (D0140) provided January 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on January 23, 2020.You asked the Plan to waive the copayment for an ER visit. You say that you left without receiving services and 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 $90 copayment for emergency care. The medical records show that you received ERservices on January 23, 2020. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 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 for an ER visit provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have toreimburse youforthetransportchair, cushion,and cup holderprovided onNovember 16, 2019.You asked the Plan to reimburse youforthe transport chair, cushion,and cup holder.You say that the Plan should reimburse you. The Plan denied your request. The Plan says while the rolling chair and cushion are approved,the cup holderis not primarily medical in nature and therefore not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The cup holderat issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to reimburse youforthe transportchair, cushion,orcup holderprovided on November 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on October 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 the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on October 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided by on January 10, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you had limited resources for transportation to the hospital. 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 per one-way trip for all other members. You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 for the ambulance ride provided by on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes L1833 and L2397 provided on December 30, 2019.You asked the Plan to pay for CPT codes L1833 and L2397. 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 when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment.We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order.Therefore, we decided that the Plan does not have to pay for CPT codes L1833 and L2397 provided on December 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from November 15, 2019 through November 21, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you have paid enough by being on medication. You say that you shouldn't have to pay the cost to get off medication. 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 for all other members must pay $285 per day for days 1-7 of a hospital stay. You have been asked to pay $1,710 copayment for the inpatient stay. ($285/day x 6 days = $1,710). The inpatient stay falls within the "Inpatient hospital 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 for the inpatient stay provided from November 15, 2019 through November 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 23, 2020.You asked the Plan to pay forthe orthosis. 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. Thismeans 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 fora lumbar-sacral orthosis (L0650) provided to the enrollee on January 23, 2020.