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

We decided that the Plan does not have to pay for the medical services provided on August 22, 2019 by out of network provider.

You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says they have correctly denied payment for the service in question. 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 the medical services provided on August 22, 2019 by out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 11, 2019 by out of network provider.You asked the Plan to pay for these out of network services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.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 rendering 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 office visit provided on June 11, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forhearing aids you purchased on January 31, 2019.You asked the Plan to reimburse you forthe hearing aids.The Plan denied your request. The Plan says hearing services must be received from a participating provider in order to be covered by the Plan.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when received from a participating provider.We looked at the file and the Plan's rules. The requested provider in this case is not a participating hearing services provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to reimburse you forhearing aids you purchasedon January 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the spacer bag/reservoir (A4627) provided on April 26, 2019.You asked the Plan to pay for the spacer bag/reservoir. You say that the spacer bag/reservoir (A4627)The Plan denied your request. The Plan says this item is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the spacer bag/reservoir have not been met.Therefore, we decided that the Plan does not have to pay for the spacer bag/reservoir (A4627) provided on April 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2019 to May 14, 2019 by out of network provider, doctor. You asked the Plan to pay for office services. You say that the enrollee presented her Original Medicare card at the time of service, so you were unaware that she had this insurance.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 the medical services provided on March 5, 2019 to May 14, 2019 by out of network provider, doctor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep study rendered to you by the doctor on August 27, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 $10 copayment per day, per facility for outpatient diagnostic procedures and tests.
Review of the file shows that you had a sleep study on August 27, 2019. You have been asked to pay a $10 copayment for these services. These services fall within the outpatient diagnostic procedures and tests 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 sleep study rendered to you by the doctor on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88305) provided to the enrollee on July 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in the payment to the facility in which the services were rendered.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 88305) provided to the enrollee on July 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe oxygen provided from June 1, 2019 through September 1, 2019.You asked the Plan to waive the coinsurance forthe oxygen. You say that prior to this you were never billed for your oxygen.The Plan denied your request. The Plan says that you were billed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay 20% coinsurance for the oxygen. The oxygen falls 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 oxygen provided from June 1, 2019 through September 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided by the provider on august 2, 2019 to August 9, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you want this to be processed as in-network.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 $360 copayment per day for days 1-5. There is a $0 copayment per day for days 6-90 for inpatient hospital care/in-network. You have been asked to pay a $360 copayment per day for days 1-5. There is a $0 copayment per day for days 6-8 for an inpatient hospital stay. The total amount you are being asked to pay is $1,800 ($360 x 5 days = $1,800). This claim has been processed as in-network. An inpatient hospital stay falls within the inpatient hospital care/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay providedfrom august 2, 2019 to August 9, 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 November 8, 2018.You asked the Plan to pay fo rthe orthosis. You say that the claim should be paid. 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. This means 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 November 8, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe procedure provided on May 9, 2019.You asked the Plan to pay forthe procedure. You say that you needed the tumor removed and would like to be reimbursed for the amount you paid out-of-pocket. The Plan denied your request. The Plan says services from out-of-network providers are not covered 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.Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network services are not among those covered under this benefit.The record shows the provider is out-of-network. Therefore, we decided that the Plan does not have to pay forthe procedure provided on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider.

You asked the Plan to pay for eye examination. You say that you provided services to the enrollee and should be paid. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not 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 the medical services provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on August 28, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network 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 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 physician services provided to the enrollee on August 28, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided on March 11, 2019.
You asked the Plan to pay for assistant at surgery services. You say that this provider was called in to assist the surgeon which is in-network, and these codes are payable. The Plan denied your request. The Plan says the denial of payment for these services is correct, because assistant at surgery services are not payable to this provider type.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided by on March 11, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 3, 2019.You asked the Plan to waive the copayment for the ED visit. You say that you had to go back because the cast was too tight. You say that you were already charged a copayment for the previous day.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 $65 copayment for each emergency room visit.You have been asked to pay a $65 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the emergency department. 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 ED visit provided on August 3, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided on August 2, 2019.
You asked the Plan to pay for inpatient hospital care. You say that you are appealing the cost that was billed to you. The Plan denied your request. The Plan says that there is no prior authorization for services rendered. The Plan states contracted providers are required to provide documentation or other evidence that you were advised prior to the services being rendered that you may be financially responsible for such services if there is no authorization.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. You were referred for inpatient hospital care by the hospital. The hospital is a contract provider. The file does not show that the plan provided notice that inpatient hospital care would not be covered. Under Medicare rules, this means inpatient hospital care is considered approved by the plan. Therefore, we decided that the Plan has to pay for inpatient hospital care provided on August 2, 2019.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Partial Hospitalization Mental Health Services (90853) provided.
You asked the Plan to waive the copayment for the mental health services. You say that the copayment should only be $40. The Plan denied your request. The Plan says the correct copayment was 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 $55 copayment for Outpatient Hospital Services. You have been asked to pay a $55 copayment for the mental health services. These services fall within the Outpatient Hospital 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 Partial Hospitalization Mental Health Services (90853) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on June 19, 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 codes are 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 22558 is arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar. The definition of code 22585 is arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure). The definition of code 22853 is insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure).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 these services. Our reviewer says that the submitted records do not support the billing of codes 22558-AS-62 (1 unit), 22585-AS-62 (1 unit), and 22853-AS (2 units). Our physician reviewer found the denial for CPT codes 22558 and 22585 involves the use of modifier 62. According to the medical records, the provider was a surgical assistant, not a co-surgeon. According to CPT rules, there is a more appropriate modifier to indicate surgical assistant services. CPT code 22853 is an add-on code. Since the primary procedure, 22558, is not supported, this add-on code was not reported with the required primary procedure and is not supported.
We looked at this physician's review, the file, and Medicare rules. 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 assistant surgeon services rendered on June 19, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on August 26, 2019by the out of network provider.You asked the Plan to pay for the practitioner services. You say that the services were provided to the enrollee in good faith. You also say that the facility requested the services for the enrollee.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The requesting facility is not a network provider either. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the rest home visit provided on August 26, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department evaluation provided on July 12, 2019.You asked the Plan to pay for emergency department evaluation. You say that you are appealing with medical records, and could not find anything hospice related for this claim.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment.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 date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for an emergency department evaluation on July 12, 2019.