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

We decided that the Plan does not have to pay for the hyperthermia treatment provided by out of network provider.
You asked the Plan to pay for the hyperthermia treatment. You say that the enrollee was recommended to this provider by her treating oncologist who is in-network with the Plan. The Plan denied your request. The Plan says the out of network provider failed to contact the plan to obtain authorization for these scheduled, non-emergent services. This is not covered under the enrollee's 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 rules also say that local hyperthermia is only covered for certain cancers as an adjunct to radiation therapy. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. There is no evidence that the enrollee has a cancer for which this treatment can be covered by Medicare, nor that this is being provided in conjunction with radiation therapy as required. 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 hyperthermia treatment provided by out of network provider.
Appeal type: SNF
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 the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the out-of-network provider was no pre-authorized and there were in-network
providers available who could provide the same services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 office visit, and the hip x-ray provided by the out of network provider.
You asked the Plan to pay for the physician services. You say that you understood that if you needed a
specialist, either in or out of network, was allowed with a copayment of $45. You say that your doctor advised
he would see you in 5 years. You also say that you though insurance would cover this. The Plan denied your
request. The Plan says there are no out of network benefits for your Plan. The Plan says you self-directed for
the services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The 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, and the hip x-ray provided by the out of network provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for services provided.
You asked the Plan to pay for the ambulance services. You say that the enrollee was a nursing facility and the service to the Emergency Department was medically necessary. The Plan denied your request. The Plan says that the enrollee was an inpatient at the time of the transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee was transported from a nursing facility. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for services provided.
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 fortrain of four testing (95999) provided on July 23, 2018.You asked the Plan to pay fortrain of four testing. You say that this should be paid.The Plan denied your request. The Plan says this service is bundled into the payment of the primary service.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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denyingthe request to pay for train of four testing. Our reviewer says that the use of unlisted CPT code 95999 to support train of four testing is not supported. Our physician reviewer found According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Modifier 59 does not change this coding rule.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on July 23, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on June 17, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you should not be responsible for the copayment because the ambulance did not initially take you to your preferred hospital due to a "money issue." The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way trip for ground travel. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride on June 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hereditary cancer risk assessment provided to the enrollee on June 26, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found te available documentation in the case file does not supportthat a hereditary cancer risk assessment was medically reasonable and necessary for the enrollee in this case. The case file consists of a Letter of Medical Necessity for Hereditary Cancer Genetic Testing, a Clinical Summary, and a Test Results Summary ofthe genetic testing. It has not been adequately demonstrated how this testing would impact the health of the enrollee. Testing which has no proven relation to the management and outcome of a medical condition, for the health of an enrollee, is not a covered Medicare benefit.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe hereditary cancer risk assessment provided to the enrollee on June 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on June 26, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for ambulance services. You have been asked to pay a $225 copayment for an ambulance trip. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided on June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the face mask purchased on July 21, 2019.
You asked the Plan to pay for the face mask. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says the provider is not licensed by Medicare.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the face mask have not been met. You purchased the face mask
from a non-licensed Medicare provider and according to the Original Medicare and your contract there is no
coverage for services obtained from provider not licensed by Medicare. Therefore, we decided that the Plan
does not have to pay for the face mask purchased on July 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the revascularization procedure and laboratory services provided on July 9, 2019.You asked the Plan to waive the copayments for revascularization procedure and laboratory services. You say that this is an error. You say the billing should be corrected.The Plan denied your request. The Plan says the copayments 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 $175 for each Medicare-covered in-network outpatient hospital facility visit and $35 per day, per provider, for in-network Medicare-covered lab services. You have been asked to pay $175 for the revascularization procedure. You have also been asked to pay $30.59, which is less than the standard $35 copayment for laboratory services. The revascularization procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayments for the revascularization procedure and laboratory services provided on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vectra DA blood test provided on August 1, 2019.You asked the Plan to pay for the Vectra DA blood test. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the Vectra DA blood test provided on August 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for trabeculoplasty by laser surgery (65855) provided on September 13, 2019.You asked the Plan to waive the copayment for laser surgery. You say that you should not have a copayment on this service.The Plan denied your request. The Plan says this service processed correctly according to your EOC.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each outpatient surgery. You have been asked to pay a $126.42 for laser surgery. The allowed amount for this service is less than the copayment listed in the EOC. 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 fortrabeculoplasty by laser surgery (65855) provided on September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on June 13, 2019.You asked the Plan to pay for the dental services. You say that you were seen for an emergency situation.The Plan denied your request. The Plan says that services received outside of the United States are not covered under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover dental services outside of the United States.We looked at the file and Medicare rules. The file indicates you received these services outside of the United States. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pay for the dental services provided on June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography services provided on February 22, 2019.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 there is a more appropriate code to use.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 95886 is "needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels."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 not coded correctly. Our coding reviewer found CPT code 95886 is not supported. The medical record does not contain evidence that a complete needle electromyography of the extremities was performed during this episode of care.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 not been met.Therefore, we decided that the Plan does not have to pay for needle electromyography services provided on February 22, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital physician services provided on May 10, 2019.You asked the Plan to pay for emergency care. You say that the enrollee was already a patient in the hospital when services were rendered.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.The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. The record shows that the enrollee presented to the hospital on an emergency basis, and does not show that the enrollee's emergency medical condition had been stabilized at the time this service was provided. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case.Therefore, we decided that the Plan has to pay for inpatient hospital physician services provided on May 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 5, 2019 by an out of network provider.You asked the Plan to pay foroffice services and lab tests. You say that the provider did not tell you that they were out-of-network.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network withthe Plan and you could have been treated by an in-network provider.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 April 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drugs provided September 17, 2018 to September 21, 2018 by"the hospital".You asked the Plan to pay forthe self-administered drugs. You say that the drugs provided by the hospital should be covered.The Plan denied your request. The Plan says self-administered drugs are generally not covered under Medicare Part B benefits.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requestedhere are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forself-administered drugs provided September 17, 2018 to September 21, 2018 by"the hospital".
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasonic guidance rendered on July 10, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.We looked at the file and Medicare rules. The file shows that procedure code 76942 was not billed with the required -26 modifier to allow for separate payment of the professional component. 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 forthe ultrasonic guidance rendered on July 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided by "the provider" on May 19, 2019.You asked the Plan to waive the copayment forthe ambulance services. You say that you were told the max Out Of Pocketwould be less and would have been met.The Plan denied your request. The Plan says you were charged this cost sharing correctlyas the enrollee was still under the Saver Rx plan on the date of service.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 they must pay a $325 copayment for each ambulance day of service. The enrollee had one ambulance day of service. The Plan charged $325 for these services. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ambulance servicesprovided by "the provider" on May 19, 2019.