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

We decided that the Plan does not have to pay forthe office consultation rendered to enrollee on October 22, 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 procedure code 99244 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. The provider submitted a claim for code 99244. This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe office consultation rendered to enrollee on October 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe therapeutic radiology simulation provided on October 29, 2019.You asked the Plan to waive the copayment forthe therapeutic radiology simulation. You say that the cost is a lot. You say that you want help with the copayment. 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 $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service.You have been asked to pay a $60 copayment for the therapeutic radiology simulation. The therapeutic radiology simulation falls 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 copayment forthe therapeutic radiology simulation provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that you are appealing based on medical necessity.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 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 topay 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 October 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 16, 2019.You asked the Plan to pay for the physician's services. 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 physician's services. We found no exception that would require the Plan to pay for these ervices. Therefore, we decided that the Plan does not have to pay for physician's services providedon July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe Inogen One G3 portable oxygen concentrator on September 23, 2019.You asked the Plan to reimburse you forthe portable oxygen concentrator. You say that you went outside of the plan because the Plan supplier offers nothing but old, antiquated equipment.The Plan denied your request. The Plan says you do not have out-of-network benefits and purchased oxygen equipment is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage.We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe Inogen One G3 portable oxygen concentrator on September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe hernia repair provided on June 25, 2019.You asked the Plan to waive the coinsurance forthe hernia repair. You submitted your bill for review. You say that you should be reimbursed.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered surgery or other services provided to you at an in-network ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $386.40, which is 20% of the allowed amount for the hernia repair. The allowed amount is $1,931.97 (20% x $1,931.97 = $386.40). The hernia repair falls within the "Outpatient Surgery andOther Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 hernia repair provided on June 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab tests provided on September 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab tests. You say that these lab services are specific and contracted laboratories may not be able to provide these services.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 inthis 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 foroutpatient lab tests provided on September 19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral evaluation (D0150), intraoral -complete series of radiographic images(D0210) and prophylaxis -adult (D1110) provided on October 16, 2019 and October 23, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the cost share was applied correctly per your plan 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.Date of service October 16, 2019-For code D0150 the provider billed $102.00. The allowable amount for the service is $27. The plan paid 100% of the allowable per the benefits outlined in the Mandatory Supplemental Dental. The plan paid $27. The member is responsible for all fees in excess of the allowed amount, $75 ($102 -$27). The $75 which was assessed as a member responsibility is correct. For code D0210 the provider billed $155.00. The allowable amount for the service is $61. The plan applied a $40 Out of network office copay and paid 100% after the copay incorrectly. The plan sent the claim back for processing to pay the $40 copay. The plan paid the total of $88. The member will be responsible for all fees in excess of the allowed amount, $94 ($155 -$88). The $94 which was accessed as member responsibility is correct. Date of service October 23, 2019-For code D1110 the provider billed $110.00. The allowable amount for the service is $41. The plan applied a $40 Out of network office copay incorrectly. The plan sent the claim back for processing to pay the $40 copay. The plan paid the total of $41. The member will be responsible for all fees in excess of the allowed amount, $69 ($110 -$41). The $69 which was accessed as member responsibility is correct.Therefore, we decided that the Plan does not have to pay forcomprehensive oral evaluation (D0150), intraoral -complete series of radiographic images (D0210) and prophylaxis -adult (D1110) provided on October 16, 2019 and October 23, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist office visits provided on October 21, 2019 and November 21, 2019.You asked the Plan to waive the copayments forthe specialist office visits. You say that you saw the nurse practitioner and do not feel you should be charged the specialist copayment. 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 $30 copayment for each specialist visit for Medicare-covered benefits. You have been asked to pay a $30 copayment for each of the specialist office visits. The specialist office visits fall within the "Physician/Practitioner Services, including Doctor's Office Visits" 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 forthe specialist office visits provided on October 21, 2019 and November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the omalizumab injection and therapeutic injection provided on October 3, 2019. You asked the Plan to waive the coinsurance for the omalizumab injection and therapeutic injection. You say that you were misinformed of the payment you would be responsible for. The Plan denied your request. The Plan says the coinsurance applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for chemotherapy drugs (including other related chemotherapy services), biologicals and other drugs covered by Medicare Part B. You have been asked to pay a total of $306.35 for the omalizumab injection and therapeutic injection. The omalizumab injection and therapeutic injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the omalizumab injection and therapeutic injection provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral medial branch blocks at L3-L4-L5.
You asked the Plan to pre-approve the blocks. You say that this is medically necessary as the second step from an already approved injection. The Plan denied your request. The Plan says the previous block only led to a 50% improvement in symptoms.
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 pre-approve the blocks. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found 80% pain relief is required to be documented from the first set of medial branch blocks. This was not achieved. The requested procedure is deemed not medically reasonable or necessary. 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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral medial branch blocks at L3-L4-L5.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for PT provided on October 1, 2019.
You asked the Plan to waive the deductible for PT. You say that you disagree with the charges because you should have met the deductible at this point in the year. 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. Your contract with the Plan says that there is a $51 deductible for outpatient rehabilitation services. You received PT on October 1, 2019. The record shows that you had paid $0 toward the $51 deductible. Therefore, you are responsible to pay the $51 deductible. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $51 deductible for outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time PT was received on October 1, 2019. Therefore, we decided that the Plan does not have to waive the deductible for PT provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for enteral formula, nutritionally complete with intact nutrients (B4150) provided June 7, 2019. You asked the Plan to pay for enteral formula. You say that the records should support the necessity of the service in dispute. The Plan denied your request. The Plan says the diagnosis code is invalid, requires 6th digit to provide appropriate specificity. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of diagnosis code K56.69 is other complete intestinal obstruction. We find that CPT code K56.69 should not be used for reimbursement purposes and is therefore an invalid diagnosis code. Based on this information, we decided that Medicare rules for coverage of enteral formula have not been met. Therefore, we decided that the Plan does not have to pay for enteral formula, nutritionally complete with intact nutrients (B4150) provided June 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing provided to the enrollee on July 8, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says train of four is considered integral to the primary procedure and therefore is part of a bundled payment.
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 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." We find that CPT code 95999 is not supported in the medical record. Specifically, payment for this code is included in the payment for the primary procedure, which was already paid for. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing provided to the enrollee on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided on November
7, 2019.
You asked the Plan to waive the copayment for radiation treatment. You say that the cost is a lot. You say that
you want help with the copayment. 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 $60
copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service.
You have been asked to pay a $60 copayment for the radiation treatment. The radiation treatment falls 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 copayment for radiation treatment provided on November 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on February 18, 2019. You asked the Plan to waive the copayment for the CT scan. You say that the copayment should have been billed months ago. You say that you are not responsible for the error. 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 $225 copayment for each in-network, Medicare-covered advanced imaging service. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls 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 copayment for the CT scan provided on February 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 1, 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided by in-network provider on November 8, 2019 to November 11, 2019. You asked the Plan to waive the copayment for radiation treatment. You say that you cannot afford this copayment. 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 $60 copayment for outpatient diagnostic testing/in-network/radiation. You have been asked to pay a $60 copayment for radiation treatment. Radiation treatment falls within the outpatient diagnostic testing/in-network/radiation 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 radiation treatment provided by an in-network provider on November 8, 2019 to November 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee on May 2, 2019 to May 31, 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 claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with the proper HIPPS code. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required HIPPS code. 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 home health services rendered tothe enrollee on May 2, 2019 to May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided by an in-network provider on November 1, 2019. You asked the Planto waive the copayment for radiation treatment. You say that you cannot afford this copayment. 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 $60 copayment for outpatient diagnostic testing/in-network/radiation therapy. You have been asked to pay a $60 copayment for radiation treatment. radiation treatment falls within the outpatient diagnostic testing/in-network/radiation therapy 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 radiation treatment provided by an in-network provider on November 1, 2019.