Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, porcelain or ceramic crown, resin-based composite, and comprehensive oral evaluation provided from April 10, 2019 to May 20, 2019.You asked the Plan to pay for the prophylaxis, porcelain or ceramic crown, resin-based composite, and comprehensive oral evaluation. You say that you would not have accepted the services if you had known that your plan did not pay for services rendered by out-of-network providers.The Plan denied your request. The Plan says you contacted the Plan prior to the services being rendered and were given the name of an in-network provider. The Plan also says that you did not confirm the status of the practitioner, nor did you verify 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, the requested items or services are not covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay for the prophylaxis, porcelain or ceramic crown, resin-based composite, and comprehensive oral evaluation provided from April 10, 2019 to May 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on March 18, 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 and the ordering provider was not in network.
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 medical services provided to the enrollee on March 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the power lift recliner purchased from August 8, 2019.You asked the Plan to reimburse you for the seat lift chair. You say that your medical team indicated this purchase would be medically necessary for you post op recovery.The Plan denied your request. The Plan says the supplier is not a certified Medicare supplier and therefore the seat lift mechanism of the seat lift chair is not reimbursable.The Plan must follow Medicare rules. The rules say Medicare does not pay for the upholstered portion of a seat lift chair. The rules also say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to reimburse you forthe power lift recliner purchased on August 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 24, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare-prohibited action.
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 for laboratory testing provided on March 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and coinsurance foran office visit (99213), Leuprolide acetate (J9217) and chemo administration (96402) provided on July 18, 2019.You asked the Plan to waive the copayment and coinsurance for the office visit, chemo drug and administration. You say that you overpaid for the services rendered on July 18, 2019. The Plan denied your request. The Plan says the cost shares were correctly applied and are a contractual obligation that cannot be waived.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 specialist services and 20% coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug. You have been asked to pay a $20 copayment for the office visit. This is the correct copayment. You have been asked to pay $134.58 for the Leuprolide acetate. The allowed amount for this service is $627.90. $627.90*20% = $134.58.You have been asked to pay $5.75 for the chemo administration. The allowed amount for this services is $28.77. $28.77*20% = $5.75You have been asked to pay a total amount of $160.33 for services rendered on July 18, 2019. $20 + $134.58 + $5.75 = $160.33. This is the correct amount. 
You have been asked to pay $160.33 for the office visit, chemo drug and administration. the office visit, chemo drug and administration fall within the specialist visit and Part B Drug benefit categories. 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 and coinsurance for an office visit (99213), Leuprolide acetate (J9217) and chemo administration (96402) provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen concentrator and battery pack.
You asked the Plan to pay for these items. You say that you have COPD and need these items. The Plan denied your request. The Plan says that this is not eligible for coverage.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for the portable oxygen concentrator and battery pack.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided by on August 8, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 physician's services provided on August8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on June 11, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible andavailable.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 servicesat 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 subsequent nursing facility careprovided on June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided to enrollee on November 30, 2018.You asked the Plan to pay for the hospital discharge day management services. 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 supported by the documentation.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 99239 is Hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed. A documented duration of time of 31 minutes or more is required to support this code. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided to the enrollee on November 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on February 27, 2019.You asked the Plan to pay for hospital discharge day management. You say that this should be reprocessed.The Plan denied your request. The Plan says this code is not supported by the documentation.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 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, the submitted medical records do not contain documentation showing that 31 minutes or more were spent on this service. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met.Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) provided on February 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 7, 2018.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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.Therequested 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 physician's services provided on November 7, 2018.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided on July 25, 2019.You asked the Plan to pay for office visit. You say that this visit should have been covered by the Plan because your coverage was in effect until July 31, 2019.The Plan denied your request. The Plan says that 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.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide any medical records for this service, nor did the Plan provide any documented attempts to obtain medical records from the provider. Without this information, we cannot determine whether this service meets the Medicare criteria for urgent out-of-area care. Therefore, the Plan has not shown that its decision to deny payment for this service is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for an office visit provided on July 25, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 13, 2019 by an out of network provider.
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 were rendered by a non-network provider without prior authorization.
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 June 13, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on June 4, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on June 4, 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 June 23, 2019 through July 1, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that the denial of nursing care extended the stay by 4 days. You say that some of the expenses should be waived.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). The enrollee's contract with the Plan clearly says that enrollees must pay $285 per day for days 1-7 and $0 per day for days 8-90 for each medically necessary in-network inpatient stay. The enrollee has been asked to pay a $1,995 copayment for the inpatient stay.($285/day x 7 days = $1,995). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that the enrollee was an inpatient for 9 days. 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 inpatient stay provided from June 23, 2019 through July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 7, 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 services were rendered by a non-participating provider without prior authorization.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 forthe medical services provided on August 7, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment amount. 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 $350 copayment per day, days 1-5 for each medically necessary covered in-network inpatient stay. You have been asked to pay a $350 copayment for each day of the inpatient hospital stay. ($350 x 5 = $1,750). The 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 the inpatient hospital stay provided.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for PT provided by the practice from July 2, 2019 to July 29, 2019.
You asked the Plan to waive the copayments for PT. You say that you should only owe a $10 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for PT provided in an outpatient hospital facility. You received PT from July 2, 2019 to July 29, 2019 for a total of 8 visits. Therefore, you are responsible to pay a $40 copayment per each visit. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you is: $40 (copayment) x 8 (PT visits) = $320.00. You have been asked to pay the total copayment amount of $320.00 for PT. PT falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for PT provided by the practice from July 2, 2019 to July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foracupuncture services (97810 and 97811) provided by the provider from August 19, 2019 to August 20, 2019.You asked the Plan to pay foracupuncture services. You say that this is the only treatment that has helped you.The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers acupuncture only when billed on the same date as surgery.The services at issue in this appeal are acupuncture services. The record does not show that they were billed on the same date as surgery.Therefore, we decided that the Plan does not have to pay foracupuncture services (97810 and 97811) provided from August 19, 2019 to August 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you thought you were having a heart attack and an ambulance was called. The responding paramedics tested you and suggested you go to the hospital. You say that your son took you to the hospital since you thought it would be a waste of money to go by ambulance.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 notprovide transport services on June 29, 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 forthe ambulance services.