Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 13, 2019 through August 17, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are unable to afford to pay the copayment. 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 provided from August 13, 2019 through August 17, 2019. You are asked to pay a $350 copayment per day, for days 1-4 of your inpatient hospital care (August 13, 2019 through August 16, 2019). 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 from August 13, 2019 through August 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 1, 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 Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on May 1, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on March 14, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 home visit provided on March 14, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, and laryngoscopy provided on July 31, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit, and laryngoscopy provided on July 31, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services rendered to the enrollee.
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 was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that procedure codes that require the use of devices must also be billed with the device code. We looked at the file and Medicare rules. The file shows that the procedure code was not billed with the required device 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 outpatient surgical services rendered to the enrollee.
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 from July 5, 2019 to July 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with the treatment authorization code and Q code. We looked at the file and Medicare rules. The file shows that the claims were not billed with the required treatment authorization code and Q 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 to the enrollee from July 5, 2019 to July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on June 5, 2019.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include documentation of advance care planning including the explanation and discussion of advance directives.
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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted does not indicate that advance care planning was rendered on this date of service. Based on this information, we decided that Medicare rules for coverage of the advance care planning. have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning (99497) provided on June 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on August 14, 2019 by the out of network provider.
You asked the Plan to pay for the practitioner services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee was referred for the services by her non-participating nursing facility. The Plan also says that the services were not urgent or emergent.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The referring facility is not a network provider either. 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 rest home visit provided on August 14, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate (CPT V2784) provided.
You asked the Plan to pay for the polycarbonate. The Plan denied your request. The Plan says that the plan allows coverage for standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating). Polycarbonate lenses are clearly excluded in the Plan's Evidence of Coverage.
The Plan must follow Medicare rules. Medicare rules say that the use of polycarbonate or similar material (V2784) for indications such as light weight or thinness will be denied as a non-covered deluxe feature. We looked at the file and Medicare rules. Medicare says that the use of polycarbonate or similar material (V2784) for indications such as light weight or thinness will be denied as a non-covered deluxe feature. The Plan says that polycarbonate lenses are an exclusion. Therefore, we decided that the Plan does not have to pay for polycarbonate (CPT V2784) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from September 4, 2019 to September 11, 2019.
You asked the Plan to pay for home infusion therapy. You say that this is a valid code. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. It has a status indicator of "I." We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from September 4, 2019 to September 11, 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.
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 management 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee by the provider on September 14, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee by the Provider on September 14, 2019.
Benefits for these services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 9, 2019 by an 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 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 referring provider 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 laboratory services provided on August 9, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular implant provided by the provider on August 13, 2019.
You asked the Plan to pay for the mandibular implant. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the mandibular implant provided by the provider on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for anesthesia services provided on July 12, 2019
You asked the Plan to waive the coinsurance for the anesthesia services. You say that you would like reconsideration as you were not given anesthesia during the cataract removal surgery. The Plan denied your request. The Plan says this claim was processed in accordance with your EOC contract.
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% coinsurance for outpatient hospital services. You have been asked to pay a 20% coinsurance for the anesthesia services. The anesthesia services fall 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 coinsurance for anesthesia services provided on July 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 23, 2019.You asked the Plan to pay for office visit. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment of this claim.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. the enrolle was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay foran office visit provided on July 23, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by the practice from June 17, 2019 to September 5, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.
Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by the practice from June 17, 2019 to September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the provider from August 3, 2019 to October 22, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided by the provider from August 3, 2019 to October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 10, 2019 to May 31, 2019 by the out of network provider.
You asked the Plan to pay for the nursing home visits. You say that you would like reconsideration as the services were medically necessary. The Plan denied your request. The Plan says these services were not authorized by the Plan.
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 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 May 10, 2019 to May 31, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ostomy supplies provided from April 6, 2019 to September 18, 2019.You asked the Plan to waive the coinsurance forthe ostomy supplies. You say that you have never had to pay for supplies before. You say that you understand the benefit has changed but you do not agree with it. 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 20% coinsurance for Medicare-covered ostomy supplies. You have been asked to pay $56.72 for the ostomy supplies. The ostomy supplies fall within the "Prosthetic devices and related supplies" benefit category. See chart below.Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityApril 6, 2019Ostomy pouch$40.0020%$8.00April 11, 2019Ostomy pouch$81.2020%$16.24July 5, 2019Ostomy pouch$81.2020%$16.24September 18, 2019Ostomy pouch$81.2020%$16.24Total$56.72
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 ostomy supplies provided from April 6, 2019 to September 18, 2019.