Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services provided to the enrollee on January 9, 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 based upon review of the submitted information, including the operative report, there is no documentation of unusual or complex circumstances or exceptional difficulty that would require the services of an assistant and warrant an exception to the policy.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 11981. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that an assistant surgeon was not medically reasonable or necessary in this case. Our physician reviewer found it is noted that no qualified resident surgeon was available. However, the documentation is insufficient to demonstrate that the use of an assistant surgeon was medically reasonable and necessary in this case. The operative note does not report what the assistant did in the case. 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 for assistant surgeon services provided to the enrollee on January 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a monitoring feature/device (HCPCS A9279).
You asked the Plan to pre-approve the device. You say that your current CPAP machine is broken. The Plan denied your request. The Plan says this is not a covered benefit.
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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the request is for a monitoring feature/device (HCPCS A9279). However, the information from you is that his CPAP machine is broken, and he needs a replacement. A9279 is not a CPAP device, or a required accessory. It is not clear what the A9279 is for, but it appears the requested HCPCS code may be an error. No information is provided about how old your CPAP device is, or whether servicing has been attempted. There are no medical records provided. Therefore a monitoring feature/device (HCPCS A9279) is considered not medically 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a monitoring feature/device (HCPCS A9279).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 1,
2018 to June 2, 2018.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF
services. The Plan denied your request. The Plan says the 100 day SNF benefit is exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from August 11, 2017 to May
4, 2018. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pay for the skilled nursing facility (SNF) services provided June 1, 2018 to June 2, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the heart ablation procedure on June 27, 2019.
You asked the Plan to reduce the coinsurance for the heart ablation procedure. You say that you were told you would only be responsible for a $250 payment. 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 5% of the cost of the facility visit. You have been asked to pay $974.90, which is 5% of the allowed amount for the heart ablation procedure. The allowed amount is $19,498.06. ($19,498.06 x 5% = $974.90. The heart ablation procedure 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 reduce the coinsurance for the heart ablation procedure on June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on June 5, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted discharge summary does not support hospital discharge day management of more than 30 minutes was performed.
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 record does not indicate that more than 30 minutes of hospital discharge day services were rendered. 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 more than 30 minutes of hospital discharge day management services (99239) provided on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 11, 2018.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan stated that the billed CPT code 99495 requires Transitional Care Management Services with the enrollee and/or caregiver within 2 business days of discharge. Transitional Care Services cannot be considered until we have received a facility discharge claim. A corrected claim was requested on October 24, 2019, November 6, 2019, November 14, 2019 and November 18, 2019. Those requests were not responded to.
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, code 99495 cannot be paid as billed as there is no claim information showing inpatient care was provided to the enrollee. A facility claim and corrected claim are required. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
We looked at the file and Medicare rules. The Plan has requested medical records to show the requested CGM
meets the Medicare criteria for medical necessity. Those records have not been provided. The documentation
that was submitted states that you are not insulin-dependent. 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on March 14, 2019 by out of network provider.
You asked the Plan to pay for SNF services. You say that you are not aware the enrollee's insurance when you see the enrollee. The Plan denied your request. The Plan says the member does not have out of network benefits.
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 on March 14, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided on July 1, 2019 to July 4, 2019.
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you are on disability and you cannot afford this coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 5% coinsurance for inpatient hospital care/network. You have been asked to pay a 5% coinsurance of the allowed amount for an inpatient hospital stay. The allowed amount is $14,643.80. The total amount you are being asked to pay is $732.19 ($14,643.80 x 5% = $732.19). The correct coinsurance has been applied to the inpatient hospital stay that was provided. An inpatient hospital stay falls within the inpatient hospital care/network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided on July 1, 2019 to July 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator and supplies provided on September 12, 2019 by out of network provider.
You asked the Plan to reimburse you for the Respironics SimplyGo Portable Unit. You say that you did not know you had to use a network provider. The Plan denied your request. The Plan says the supplier is non participating and you did not get 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 reimburse you 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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to reimburse you for these items. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator and supplies provided on September 12, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for an orthotic management and training assessment provided on August 12, 2019.
You asked the Plan to waive the copayment for orthotic assessment. You say that this service was not done in a hospital, and you do not know why this service is called physical therapy. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay $0 copayment for physician visit in an outpatient hospital facility. The place of service is considered to be an outpatient hospital facility, however this service is a physician evaluation and therefore the outpatient hospital professional service copayment applies to this claim. The Plan says you must pay $40 copayment for orthotic assessment. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for orthotic assessment. Therefore, we decided that the Plan has to waive the copayment for an orthotic management and training assessment provided on August 12, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on August 19, 2019.
You asked the Plan to pay for the ambulance services. You say that the enrollee wanted to leave the hospital and go home. The Plan denied your request. The Plan says you did not have authorization and the enrollee could have been safely transported by wheelchair van.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. You did not get prior authorization. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for services provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided from August 30, 2019 to October 4, 2019.
You asked the Plan to waive the copayments for the specialist office visits. You say that you do not feel like you should be liable for the follow-up appointments. 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 $50 copayment for Specialty physician. You have been asked to pay a $50 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. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up visit.
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 specialist office visits provided from August 30, 2019 to October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the DonJoy Iceman Clear device provided on July 19, 2019.
You asked the Plan to reimburse you for the cold therapy device. You say that the device was recommended to help relieve pain after your surgery. The Plan denied your request. The Plan says cold therapy devices are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cold therapy device have not been met. Cold therapy devices are not covered by Medicare. You signed an Advance Beneficiary Notice for the supplier stating the device is not covered. Therefore, we decided that the Plan does not have to reimburse you for the DonJoy Iceman Clear device provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and pertussis (TDaP) vaccine rendered to you on August 12, 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 vaccine is not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and pertussis (TDaP) vaccine rendered to you on August 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided August 13, 2019 to August 16, 2019
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were transferred from one hospital to another. You paid your copay for your stay at the first hospital and you do not understand why you're being charged another inpatient hospital copay. The Plan denied your request. The Plan says the correct copayment was applied per the 2019 Evidence of Coverage.
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 $350 per day for days 1-5 each time you are admitted to an acute care. You have been asked to pay $350 per day for days 1-5. ($350 x 3 = $1,050). The health plan contract says each time you are admitted to an acute care hospital you pay $350 per day. 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 August 13, 2019 to August 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on June 24, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. The provider submitted a claim for procedure code 99232 (subsequent hospital care). The Plan previously paid this code for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on June 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August 26, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you feel like these four visits could have been done in two visits. 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 $40 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $40 copayment for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 specialist office visit provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 by 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 an out-of-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 September 4,
2019 by out of network provider.