Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and sleeve provided to the enrollee on February 23, 2019.
You asked the Plan to pay for these items. The Plan denied your request. The Plan says that your request is not a covered benefit.
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 the knee orthosis and sleeve provided to the enrollee on February 23, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a routine eye examination (eye refraction) provided on August 14, 2019.You asked the Plan to pay for eye refraction. You say that this charge should be paid by the Plan.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because routine eye exams (eye fractions) are not covered by Medicare.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 one routine eye exam per calendar year.We looked at the file and the Plan's rules. The Plan covers one routine eye exam per calendar year. Based on this information, we decided that the Plan's rules for coverage of eye refraction have been met.Therefore, we decided that the Plan has to pay fora routine eye examination (eye refraction) provided by the physician on August 14, 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 waive the copayment for an office visit (99215) and a breathing capacity test (94010 and 94729) provided on July 31, 2019.You asked the Plan to waive the copayment for the office visit and breathing test. You say that you would like reconsideration because there should only be one copayment for the services rendered. The Plan denied your request. The Plan says per the EOC, you are liable for the $20 copayment for the office visit and breathing test.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 outpatient diagnostic testing. You have been asked to pay a $20 copayment for the office visit and breathing test. The office visit falls within the specialist services benefit category and the breathing test falls within the outpatient diagnostic testing 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 office visit (99215) and a breathing capacity test (94010 and 94729) provided on July 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the enrollee on May 11, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that this should be covered because it was medically necessary.The Plan denied your request. The Plan says that the copayment was assessed 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 a $265 copayment for Ambulance services. The enrollee has been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the Ambulance services benefit category. 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 forthe ambulance transport provided to the enrollee on May 11, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hospital outpatient observation stay provided on September 6, 2019.
You asked the Plan to waive the copayment for observation. You say that you should not be responsible for an observation copayment because the Magnetic Resonance Imaging (MRI) machine was over-booked, but the hospital staff did not want to release you until you had this test. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $450 copayment for observation. You have been asked to pay $450 copayment for observation. Observation falls 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 a hospital outpatient observation stay provided on September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 6, 2019 to July 24,
2019 by out of network provider.
You asked the Plan to pay for the office visit, anesthesia and nursing facility care. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says services from
non-participating providers are not covered unless preauthorized.
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 6, 2019 to
July 24, 2019 by out of network provider.
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 your plan has an ambulance coverage benefit and it does not clarify that you are liable if you were not transported to the hospital. You say you should only be liable for an ambulance copay.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 July 7, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by the practice from May 7, 2019 through May 14, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you were informed that there was no copay for inpatient stays for days 1-7.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from May 7, 2019 through May 14, 2019. You were charged the correct copay for days 1-6, which leaves the member responsible for $1,770.00. 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 inpatient hospital care provided by the practice from May 7, 2019 through May 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient hospital care. Our physician reviewer found the review indicates that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility. There was no documentation provided necessitating post stabilization care services at the nonplan facility. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 8, 2019 by out of network provider.You asked the Plan to pay for these services. You say that you do not want to change doctors.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-approvethe 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 8, 2019 by out of network provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered to you from May 7, 2019 to May 9, 2019.You asked the Plan to waive the copayment for these services. You say that you are being billed $175 after paying the bill.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 $425 copayment per admission for inpatient hospital care. Review of the file shows that you received inpatient hospital services from May 7, 2019 to May 9, 2019. You have been asked to pay a $425 copayment for these services. These services fall 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. The file shows that you have paid $250 towards the copayment, leaving a remaining amount of $175 to satisfy the $425 copayment. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered to you from May 7, 2019 to May 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided.
You asked the Plan to waive the copayment for laboratory services. You say that you gave a sample before your appointment. You are wondering why this was not paid. 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 $40 copayment for each Medicare-covered laboratory test at an in-network outpatient hospital facility. You have been asked to pay $23.75, which is less than the standard $40 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a drainage abscess or hematoma (300), and an intranasal biopsy (301) provided by out of network provider.
You asked the Plan to pay for a drainage abscess or hematoma, and an intranasal biopsy. You say that you are appealing claim payment denial for services rendered to your member on the date of service. The Plan denied your request. The Plan says the attending provider is a non-participating provider. The plan did not authorize any services for the provider or the doctor as they are non-participating providers. The Plan further says that non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollees EOC.
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 a drainage abscess or hematoma (300), and an intranasal biopsy (301) provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by out of network provider.You asked the Plan to pay for office visit. You say that you would like this claim 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 the medical services provided on July 18, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee on May 2, 2018 by out of network provider.You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says that there was no hospital admission authorization on file.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 skilled nursing facility (SNF) services provided to the enrollee on May 2, 2018 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided to the enrollee on March 12, 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 insufficient documentation was submitted to show coverage criteria for this testing were met.The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. In this case, insufficient documentation was submitted to show the results of this testing would be used to treat active illness or disease as opposed to being used for screening purposes. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided to the enrollee on March 12, 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 are on a fixed income and you cannot pay the bill. You say that you did not want the ambulance called and just needed to eat something because your blood sugar was low.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 July 19, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 24, 2019 by out of network provider.You asked the Plan to pay for the physician services. You say that the provider was a visiting physician in the building that you live in and was advised that the plan was accepted but was not aware of the benefit.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 on July 24, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a bone fixation device (20690) provided on June 3, 2019.You asked the Plan to pay for the application of a bone fixation device. You say that the assistant surgeon was chosen by the operation surgeon and had no choice in rendering the medically necessary services. The Plan denied your request. The Plan says the services of a co-surgeon, assistant surgeon or surgical team are not covered for this procedure.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 20690. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the application of a bone fixation device have not been met. Therefore, we decided that the Plan does not have to pay for the application of a bone fixation device (20690) provided on June 3, 2019.