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

We decided that the Plan does not have to waive the copayment for the ultrasound provided on January 27, 2020.You asked the Plan to waive the copayment for the ultrasound. You say that your mammogram should be covered.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 $20 copayment for x-rays and ultrasounds. You have been asked to pay a $20 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed for the ultrasound and there was no copayment applied to the mammogram.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 ultrasound provided on January 27, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on January 16, 2020.
You asked the Plan to pay for the non-emergency transportation. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider has billed with an invalid place of treatment code.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The claim has physician office as place of treatment but the address is an Urgent Care. The provider must correct the claim. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pay for services provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on November 26, 2019.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 one unit of procedure code 99232 has already been paid.The Plan must follow Medicare rules. The rules say that only one hospital discharge day management service is payable per patient per hospital stay.We looked at the file and Medicare rules. The file shows that the Plan has paid code 99232 for the enrollee. Further payment of this code cannot be made.Therefore, we decided that the Plan does not have to pay for the hospital discharge services rendered on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a handicap bathtub or shower.
You asked the Plan to pre-approve a handicap bathtub or shower. You say that these items are medically
necessary for you. The Plan denied your request. The Plan says that a handicap bathtub or shower is not a
covered benefit under your contractual policy.
The Plan must follow Medicare rules. Medicare rules say that bathtubs and showers are not covered because
they are considered convenience items, primarily hygienic in nature.
While a handicap bathtub or shower may be appropriate for you in this case, neither the Plan nor Medicare
offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a handicap
bathtub or shower.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement services provided on June 18, 2019.You asked the Plan to waive the copayment for the debridement services. You say that the service received was not surgery. You say you paid a $35 copayment at the time of the visit. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for surgery services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the debridement services.The enrollee has been asked to pay a $144.65 copayment for the debridement services. The debridement services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that debridement services are considered surgical procedures.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 for the debridement services provided on June 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you did not use the ambulance service and
the responders did not use the ambulance to transport you. You say that the claim may have been submitted
incorrectly. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on November 24, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 5, 2019.
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 44377 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 44377 is small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple. We find that CPT code 44377 is not supported in the medical record. Specifically, there is no documentation that a small intestinal endoscopy with biopsy was performed. 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 surgical services rendered on October 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided on December 18, 2019.You asked the Plan to waive the coinsurance for the Part B drugs. You say that you work part time and cannot afford to pay this.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% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.You have been asked to pay $304.52, which is 20% of the allowed amount for the Part B drugs. The allowed amount is $1,522.56 (20% x $1,522.56 = $304.52). 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 coinsurance for the Part B drugs provided on December 18, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 14,2020 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that these services are provided in good faith for reimbursement. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for physician services provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a prosthetic eye and its fabrication (V2623 and V2628)
provided on December 11, 2019.
You asked the Plan to pay for the prosthetic eye and its fabrication. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of
delivery for the billed date of service.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the
supplies provided in this case. The record does not include an itemized shipping invoice to indicate the specific
supplies or a proof of delivery for December 11, 2019. Therefore, we decided that the Plan does not have to
pay for a prosthetic eye and its fabrication (V2623 and V2628) provided on December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (93010)provided on September 25, 2019.You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the record supports only for the strip but there is no supporting documentation for interpretation.The Plan must follow Medicare rules. Medicare rules say that a professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service.In this case, the CPT Code Manual definition of code 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010is not supported in the record. Specifically, the record does not include sufficient information to verify the interpretation of this service. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met.Therefore, we decided that the Plan does not have to pay for the electrocardiogram (93010) provided on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92014) Optic nerve scan (92133)
and eye refraction (92015) provided January 21, 2020.
You asked the Plan to pay for the vision services. You say that your PCP told you this provider is in network.
You were referred to this provider 5 years ago and you have had your annual exam with them ever since. The
Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network
provider.
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 by an in-network provider.
We looked at the file and the Plan's rules. Vision services must be rendered by an 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 comprehensive eye exam (92014) Optic nerve
scan (92133) and eye refraction (92015) provided January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from September 8, 2019 to September 17, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received inpatient care on the dates of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.
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 $335 copayment per day for days 1-5 for Inpatient hospital care. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received inpatient hospital care from September 8, 2019 to September 17, 2019. The enrollee has been asked to pay a $335 copayment per day for days 1-5 for the inpatient hospital services, totaling $1675. The inpatient hospital services fall within the Inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the enrollee's contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when the enrollee enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from September 8, 2019 to September 17, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cataract surgeries and surgical services
provided on November 5, 2019 to November 19, 2019.
You asked the Plan to waive the coinsurance for the cataract surgeries and surgical services. You say that you
do not believe you should pay more than the in-network copayment for the surgeries. You say you were told
that your provider was in-network but also told your provider was out-of-network. 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 30%
coinsurance for outpatient surgery, including services provided at out-of-network hospital outpatient facilities
and ambulatory surgical centers and 30% coinsurance for surgical services with an out-of-network specialist.
You have been asked to pay a total of $1,585.98 for the cataract surgeries and the surgical services. The
cataract surgeries fall within the "Outpatient surgery, including services provided at out-of-network hospital
outpatient facilities and ambulatory surgical centers" benefit category. The surgical services fall within the
"Physician/Practitioner services including doctor's office visits" benefit category. The record shows the
provider is out-of-network. See chart below.
Date of Service Service Allowed Amount Coinsurance Member Liability
November 5, 2019 Cataract surgery $2,008.05 30% $602.42
November 5, 2019 Surgical services $644.26 30% $190.57 - This is
less than the
standard
coinsurance
amount.
November 19, 2019 Cataract surgery $2,008.05 30% $602.42
November 19, 2019 Surgical services $644.26 30% $190.57 - This is
less than the
standard
coinsurance
amount.
Total $1,585.98
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 the cataract surgeries and the surgical services provided by
on November 5, 2019 to November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92014) fundus photography
(92250) provided January 6, 2020.
You asked the Plan to pay for the vision services. You say that you have had cataract surgery with this group
and have been going to them and was unaware that the provider was now out of network for your plan. The
Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network
provider. Non-emergent services with non-contracted providers require prior-authorization prior to services
being rendered.
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 by a network provider.
We looked at the file and the Plan's rules. Enrollee's must receive their vision services from an 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 comprehensive eye exam (92014)
fundus photography (92250) provided January 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit and an office visit provided by participating providers on January 12, 2020 to January 15, 2020.You asked the Plan to waive the copayment for an emergency room visit and an office visit. You say that you do not agree with these charges.The Plan denied your request. The Plan says the correct copayments have 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 $90 copayment and a $5 copayment for emergency care and physician/practitioner services/PCP office visit. You have been asked to pay a $65.90 which is less than your copayment amount of $90 for an emergency room visit and a $5 copayment for an office visit. The total amount you are being asked to pay is $70.90 ($65.90 + $5 = $70.90). An emergency room visit falls within the emergency care benefit category. An office visit falls within the physician/practitioner services/PCP office visit 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 emergency room visit and an office visit provided by participating on January 12, 2020 to January 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on November 1, 2019 to November 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON physical therapy services. You say that you were told these services do not need authorization.The Plan denied your request. The Plan says these services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on November 1, 2019 to November 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 9, 2019.
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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are
statutorily excluded.
The provider submitted a claim for procedure code 99190 (special pump services). This code has a status
indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.
Therefore, we decided that the Plan does not have to pay for the special pump services rendered on December
9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) provided on December 10, 2019.You asked the Plan to pay for hospital care. You say that this should be paid.The Plan denied your request. The Plan says the enrollee's primary insurance paid the full cost of this service.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. Medicare will not make a secondary payment if the provider/physician/supplier accepts, or is obligated to accept, the primary plan payment as full payment or full satisfaction of the patient's responsibility.The records show that the enrollee's primary insurance has paid more than the Medicare allowed amount for the service at issue.Therefore, we decided that the Plan does not have to pay for hospital care (99233) provided on December 10, 2019.