Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital outpatient services provided.
You asked the Plan to waive the copayment for the hospital outpatient services. You say that you would like the Plan to cover these charges because this is the only provider that can treat the enrollee. 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 50% of the Medicare-allowed amount at an out-of-network outpatient hospital facility. You have been asked to pay $57.58 which is 50% of the allowed amount for the hospital outpatient services. The allowed amount is $115.15. ($115.15 x 50% = $57.58). The hospital outpatient services fall within the "Outpatient surgery, including 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 copayment for the hospital outpatient services provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Betamethasone provided to the enrollee on September 20, 2018.
You asked the Plan to pay for this drug. The Plan denied your request. The Plan says that this is excluded from coverage.
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 requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Betamethasone provided to the enrollee on September 20, 2018.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (73560) provided by the physician on September 26, 2019.
You asked the Plan to waive the copayment for an x-ray. You say that you had knee replacement surgery on September 12, 2019 and had a follow-up appointment on September 26, 2019, which is included in the surgery with no copayment. You say you had no choice over the doctor performing the x-ray and would like this covered under your follow-up appointment, and not pay a copayment. The Plan denied your request. The Plan says outpatient diagnostic tests including x-rays have a $30 copayment for each 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 $30 copayment for outpatient diagnostic tests. You have been asked to pay a $30 copayment for an x-ray. This service falls within the outpatient diagnostic tests benefits category. The x-ray is not included as part of your surgery on September 12, 2019 because the surgery does not have what is referred to as a global period (meaning services received before or after the surgery cannot be included in the cost of the surgery). 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 x-ray (73560) provided by the physician on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transfer bench for tub or toilet (E0247) provided by the provider on September 2, 2017.You asked the Plan to pay forthe transfer bench. You say that this item is medically necessary for you not a convenience item  because you are unable to get into the shower area without using the tub transfer bench.The Plandenied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pay forthe transfer bench for tub or toilet (E0247) provided September 2, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe laboratory testing provided from June 10, 2019 to July 1, 2019 by the out of network provider.You asked the Plan to reimburse you forthe genetic testing. You say that  The Plan denied your request. The Plan says authorization was not obtained before the laboratory testing was provided to the enrollee. The Plan also says the authorizations 20190530A13405 and 20190705A16282 are not effective for the June 10, 2019 and July 1, 2019 dates and are for different 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 reimburse you 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 caseis not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to reimburse you for these items/services.Therefore, we decided that the Plan does not have to reimburse you forthe laboratory testing provided from June 10, 2019 to July 1, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound of the breast and diagnostic mammogram provided on July 18, 2019.You asked the Plan to waive the copayments for an ultrasound of the breast and diagnostic mammogram. You say that you received a mammogram screening and should not be responsible for 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 $250 copayment for outpatient diagnostic tests.The medical records show that you received an ultrasound of the breast and diagnostic mammogram on July 18, 2019.Therefore, you are responsible to pay the allowed amount of $237.44, which is less than the $250 copayment. You have been asked to pay $237.44for an ultrasound of the breast and diagnostic mammogram. An ultrasound of the breast and diagnostic mammogram 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 an ultrasound of the breast and diagnostic mammogram provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from February 25, 2019 to June 21, 2019.You asked the Plan to waive the copayments for wound debridement. You say that you disagree with 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received wound debridement from February 25, 2019 to June 21, 2019for a total of 10 services. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $250 copayment per each service. The total amount you owe is: $250 (copayment) x 10 (services) = $2,500.00.You have been asked to pay the total copayment amount of $2,500.00 for wound debridement. Wound debridement falls within the outpatient surgery, including 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 copayments forwound debridement provided from February 25, 2019 to June 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay from April 26, 2019 to May 10, 2019.
You asked the Plan to waive the coinsurance for an inpatient hospital stay. 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 40%
coinsurance for out-of-network inpatient hospital care.
You had an inpatient hospital stay at an out-of-network provider from April 26, 2019 to May 10, 2019.
Therefore, you are responsible to pay $7,049.45, which is less than the total coinsurance amount.
You have been asked to pay $7,049.45 for an inpatient hospital stay. An 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 coinsurance for an
inpatient hospital stay from April 26, 2019 to May 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post-stabilization inpatient care provided on June 15 to June 17, 2019.
You asked the Plan to pay for the inpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network hospital.
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 the inpatient services. Our reviewer says that the post-stabilization inpatient services do not meet coverage criteria. Our physician reviewer found after evaluation in the ED, the enrollee was diagnosed with gastroenteritis and duodentitis.
A treating physician documented on a formed signed and dated 6/15/19 at 16:55 that the patient was stable for transfer. The enrollee could have been transferred by ambulance to an in-network facility at that time. 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the post-stabilization inpatient care provided on June 15 to June 17, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp treatments.
You asked the Plan to pre-approve the Aranesp. You say that you do not have access to Retacrit and use Aranesp in this office. The Plan denied your request. The Plan says there are many specialty pharmacies able to send Retacrit to this location for use.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Aranesp. Our reviewer says that the requested Aranesp is not considered medically reasonable and necessary due to step therapy requirements. Our physician reviewer found the enrollee is a male with chronic kidney disease and anemia. The enrollee has not tried and failed the required drug, Retacrit. Based on the medical records provided, the plan's required drug likely would not be less effective and/or likely have adverse effects for the patient. 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp treatments.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four (95999) provided on December 17, 2018.
You asked the Plan to pay for train of four. You say that the service was medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 find that CPT code 95999 is not supported in the medical record. Specifically, train of four is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable. Based on this information, we decided that Medicare rules for coverage of train of four have not been met. Therefore, we decided that the Plan does not have to pay for train of four (95999) provided on December 17, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided.
You asked the Plan to waive the copayment for inpatient stay. You say that you were laid off and are not paying this claim. 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 $300 copayment per admission for inpatient hospital care. You have been asked to pay $300 copayment for inpatient stay. Inpatient 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 an inpatient hospital stay provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on August 29, 2019.You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you are allowed 2 cleanings per year. You also say that this is your second for the year.The Plan denied your request. The Plan says the maximum allowed for the oral exam have been met. The Plan also says that the maximum allowed for a prophylaxis limitation has been met.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, oral exam(s) are limited to 1 per year, and cleaning(s) are limited to 1 per year. The record shows that you received a prophylaxis and periodic oral evaluation on February 28, 2019 and your oral exam and cleaning benefits are now exhausted.Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 1, 2019 to October 16, 2019 by out of network provider "out of network doctor".You asked the Plan to pay forphysician services. You say that you see him every month. You say that the Plan paid for May 1, 2019.The Plan denied your request. The Plan says there are in-network available for the services in question.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 forcare 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, "network doctors" 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 1, 2019 to October 16, 2019 by out of network provider "out of network doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay formoderate sedation services provided to on July 9, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCurrent Procedural Terminology (CPT) code 99152 (1 Unit) remains not supported.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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older."We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correctin 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 99152 is not supported. The medical record does not contain evidence that moderate sedation was performed with the presence of a trained, independent observer for the duration of the sedation.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 Plandoes not haveto pay formoderate sedation services provided to on July 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have toreduce the copayment forthe arthrocentesis provided on April 25, 2019.You asked the Plan to reduce the copayment forthe arthrocentesis. You say that you were told there would only be a $35 office visit charge for the service. You say you were told by a nurse that you could have had the service done at the office and not pay the hospital 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 $270 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $270 copayment for the arthrocentesis.You have been asked to pay a $232.34 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you received this service at an outpatient hospital facility.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 topay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment forthe arthrocentesis provided on April 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 1, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are 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 laboratory services provided on May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on
July 25, 2019.
You asked the Plan to pay for the assembly and operation of a pump. You say that the perfusionist is required
to assemble and operate the pump. The Plan denied your request. The Plan says payment for this service is
included in the DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier
other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the assembly and operation of a pump have not been met. The payment for this service would be
included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the
assembly and operation of a pump (99190) provided on July 25, 2019