Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on July 8, 2020, to July 13, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were forced to stay 
in the hospital in order to receive your colonoscopy. 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 $225 
copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $225 copayment per day for days 1-5. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay is $1,125 ($225 x 5 days = 
$1,125). Since an inpatient hospital stay was provided, the correct copayment has been applied. An inpatient 
hospital 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 an inpatient hospital stay provided by a participating provider on July 8, 2020, to July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 28, 
2020, to October 29, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the enrollee could have been treated in observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was evaluated in the emergency department on October 28, 2020, with 
complaints of shortness of breath and flank pain. He had an oxygen saturation of 92-94 % on 2 liters of 
supplemental oxygen. His vital signs were otherwise unremarkable. He was admitted for possible COVID-19 
infection and flank pain. A COVID test was negative the following day and his flank pain and shortness of 
breath had resolved. He was discharged home to follow up as needed. The record does not show that at the time 
of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care 
would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from October 28, 2020, to October 29, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services rendered on November 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 11721 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 11721 is debridement of nail(s) by any method(s); 6 or 
more. 
 
We find that CPT code 11721 is not supported in the medical record. Specifically, there is no documentation of 
debridement of 6 or more nails. 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 for the debridement 
services rendered on November 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the plan to reconsider their 
decision. The Plan denied your request. The Plan says the services were paid by the enrollee's primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Review of the file shows that the 
services were paid and exceeds the payment agreement with the enrollee's primary health insurance carrier. 
The enrollee's primary insurer paid more than the allowable amount from the secondary payer. As the 
secondary insurer, the Plan cannot be held responsible for the ambulance services until the primary insurer has 
denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy services provided on 
October 12, 2020. 
 
You asked the Plan to waive the coinsurance for chemotherapy services. You say that you reached your out-of-
pocket maximum in November The Plan denied your request. The Plan says your out-of-pocket maximum was 
not met at the time of this claim. 
 
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 have an in-
network maximum out-of-pocket amount of $3000 for medical services.  
 
You have an in-network maximum out-of-pocket amount of $3000 for medical services. Chemotherapy 
services fall within the maximum out-of-pocket amount. You had not reached the maximum at the time of the 
claim. 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 chemotherapy services provided on October 
12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (96372, 97016, 97112) provided June 17, 2020. 
 
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the records do not support the services billed. 
 
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 codes 96372, 97016, & 97112 are not supported in the medical record. Specifically, the 
documentation provided does not support the CPT codes billed. The plan did request additional records, 
however none were provided. Based on this information, we decided that Medicare rules for coverage of the 
injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (96372, 
97016, 97112) provided June 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
November 17, 2020, to November 20, 2020. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that you were not admitted to the 
hospital and are questioning these charges. The Plan denied your request. The Plan says the copayment amount 
you are being charged is 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 $285 
copayment per day for days 1 to 6 for inpatient stay. The record shows that you were admitted as an inpatient 
on November 20, 2020. Therefore, the inpatient portion of this stay lasted 1 day, resulting in a copayment 
amount of $285. 
 
You have been asked to pay $285 copayment per day for days 1 to 6 for inpatient stay. 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 
an inpatient hospital stay provided from November 17, 2020, to November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chiropractic services (98941) provided by 
an out-of-network provider on September 23, 2020, to September 25, 2020. 
 
You asked the Plan to waive the deductible for chiropractic services. You say that this should be covered with a 
$20 copayment. The Plan denied your request. The Plan says the deductible had not been met when these 
services were received. 
 
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 $750 deductible for out-of-network services that are not urgent, 
emergent, or supplemental.  
 
The item or service you asked the Plan to waive the deductible for is an out-of-network service that was not 
urgent, emergent, or supplemental. The Plan has followed Medicare rules by clearly disclosing in the contract 
that there is a $750 deductible for out-of-network services that are not urgent, emergent, or supplemental. This 
cost sharing is a contractual obligation that had not been met at the time chiropractic services was received on 
September 23, 2020 to September 25, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for chiropractic services (98941) provided by an out-of-network provider on September 23, 2020, to 
September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction services (92015).

You asked the Plan to pay for the vision services. You say that you are appealing the denial of payment for service. You called and spoke to a representative and was told you would only pay $35 specialist copayment. The doctor is in network and there should be no extra charges. The Plan denied your request. The Plan says the claim was processed correctly as the provider verified that this was done as a medical refraction and the records show this was a medical examination.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered during a routine exam and performed by the designated in-network vendor.

We looked at the file and the Plan's rules. Eye refraction is covered when rendered during a routine exam and performed by the designated in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services (92015).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the chromosome analysis (88264).

You asked the Plan to pay for the chromosome analysis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in the payment to the facility.

The Plan must follow Medicare rules. Medicare rules say that payment to a hospital for laboratory tests furnished to an inpatient, whose stay is covered under Part A, is included in the PPS rate for PPS facilities.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chromosome analysis have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. Payment for this service is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the chromosome analysis (88264).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance, half leg (E0673).

You asked the Plan to pay for pressure pneumatic appliance. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. You provided the equipment for the enrollee during and/or following surgery in the facility. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Based on this information, we decided that Medicare rules for coverage of pressure pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance, half leg (E0673).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a neuromuscular stimulator (E0745) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that there is an invalid procedure code/modifier combo on the claim.

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 E0745 is "Neuromuscular stimulator, electronic shock unit."

We asked our coding 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 the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our coding reviewer found the provider reported modifier NU (new equipment purchased), with KX modifier for medical necessity. Therefore, this would be the correct modifiers to report a TENS unit. If equipment was rented modifier to report would be RR.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for a neuromuscular stimulator (E0745) provided to the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the copayment for the vision service provided on 
November 2, 2020. 
 
You asked the Plan to reimburse you for the copayment for the vision service. You say that there is no 
copayment for glaucoma screenings. The Plan denied your request. The Plan says you did not have a glaucoma 
screening exam. 
 
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 $55 
copayment for Out-of-Network for Medicare covered exams.  
 
You have been asked to pay a $55 copayment for the copayment for the vision service. The provider has 
confirmed you did not have a glaucoma screening. The copayment for the vision service falls within the Out-
of-Network Medicare covered exams 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 reimburse you for the 
copayment for the vision service provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye examination (92014) provided on November 
10, 2020. 
 
You asked the Plan to pay for a routine eye examination. You say that you thought the service would be 
partially covered, however it was determined you were referencing a 2019 EOC. The Plan denied your request. 
The Plan says that vision services rendered by an out-of-network provider are not covered. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers some vision services when the provider is in-network. 
 
We looked at the file and the Plan's rules. Out-of-network services are not covered. Based on this information, 
we decided that the Plan's rules for coverage of a routine eye examination have not been met. Specifically, 
services were provided by an out-of-network provider. The Plan has contracted providers available to provide 
these services. 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 a routine eye examination (92014) provided on November 10, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 6, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that you 
must receive your care from a network provider. In most cases, care you receive from an out-of-network 
provider (a provider who is not part of our Plan's network) will not be covered. If you need medical care that 
Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this 
care from an out-of-network provider. You, or your PCP, must obtain authorization from the Plan prior to 
seeking care. 
 
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 
laboratory services. 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 laboratory services provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing home assessment provided by an out of network (OON) provider.

You asked the Plan to pay for the OON nursing home visit. You say that the provider could not refuse medical services that were necessary for this enrollee's health and should be reimbursed for the services rendered. The Plan denied your request. The Plan says these services were not emergent and were provided OON without prior authorization which 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 had network providers available who could have provided 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 nursing home assessment provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit, urinalysis and 
electrocardiogram tracing provided on July 27, 2020. 
 
You asked the Plan to pay for the hospital outpatient clinic visit, urinalysis, and electrocardiogram tracing. The 
Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, 
care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare 
requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from 
an out-of-network provider. You, or your PCP, must obtain authorization from the Plan prior to seeking care.  
 
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 hospital outpatient clinic visit, urinalysis and electrocardiogram 
tracing provided on July 27, 2020.