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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 5, 2019 through August 6, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 5, 2019 through August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit with a specialist provided on June 26, 2019 by out of network provider, "the doctor".You asked the Planto pay foran office visit. You say that the doctor helped you with your condition and you want to continue your treatment with him. You say that your primary care physician (PCP) agrees for you to continue receiving the treatments with "the doctor".The Plan denied your request. The Plan says according to their systems the claim does not meet criteria for approval due to evidence of a non-contracted provider, did not request pre-authorization, there is no evidence of a medical emergency, or life at risk, not referred by a PCP and they have a contracted provider in the member's municipality of residence.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 foran office visit with a specialist provided on June 26, 2019 by out of network provider, "the doctor".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 23, 2019 by out of network provider.You asked the Plan to pay for a GYN office visit. You say that you performed these services in good faith for timely processing and reimbursement.The Plan denied your request. The Plan says no prior authorization was obtained for the service 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 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 May 23, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthroscopy provided by the Medical Center on June 5, 2019.
You asked the Plan to waive the copayment for arthroscopy. You say that you paid $240 at the time of service and disagree with the additional 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 $325 copayment for outpatient surgery services provided in an outpatient hospital facility. You have been asked to pay a $325 copayment for arthroscopy. Arthroscopy 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 copayment for arthroscopy provided by the Medical Center on June 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided by on September 4, 2019.You asked the Plan to reimburse you for the eyeglasses. The Plan denied your request. The Plan says the enrollee must use a plan optical facility for purchases of eyewear.Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a Plan optical facility.We looked at the file and the Plan's rules.The requested provider in this case is not a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulpal debridement, palliative (emergency) treatment of dental pain -minor procedure, first intraoral periapical x-ray, and 3 resin-based composites provided on August 20, 2019 and August 23, 2019.You asked the Plan to pay for the pulpal debridement, palliative treatment of dental pain, x-ray, and resin-based composites. You say that you do not understand why these services were not covered by your plan.The Plan denied your request. The Plan says the pulpal debridement, palliative treatment of dental pain, and x-ray are not covered benefits. The Plan also says that services performed by an out-of-network provider are not covered because your healthcare plan does not have out-of-network 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.Though the Plan offers a dental benefit in excess of Medicare coverage, pulpal debridement, palliative (emergency) treatment of dental pain -minor procedure, and first intraoral periapical x-ray are not among those covered under this benefit. The contract clearly states that you are responsible for 100% of the costs of resin-based composites when the service is provided out-of-network. The record shows that the provider you saw is out-of-network, and the Plan does not have to pay the in-network benefit rate for the resin-based composite.Therefore, we decided that the Plan does not have to pay forthe pulpal debridement, palliative (emergency) treatment of dental pain -minor procedure, first intraoral periapical x-ray, and 3 resin-based composites provided on August 20, 2019 and August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided July 11, 2018, and July 12, 2018.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the initial timely filing deadline.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until September 6, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the services provided on July 11, 2018, and July 12, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by the provider from August 13, 2019 to November 1, 2019.You asked the Plan to pay fortest 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 fortest strips, lancets, control solution, and batteries provided from August 13, 2019 to November 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT codes 73630-LT and Q4046 billed for date of service June 4, 2019.You asked the Plan to pay forthe services billed with CPT codes 73630-LT and Q4046. You say that the medical records submitted support the services in dispute.The Plan denied your request. The Plan says the CPT codes which remain in dispute are not supported by the documentation provided.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 73630-LT is a complete radiologic examination of the left foot with a minimum of 3 views. The CPT Code Manual definition of code Q4046 is cast supplies for a fiberglass short leg splint.We find that CPT codes 73630-LT and Q4046 are not supported in the medical record. Specifically,the medical record does not specify how many radiological views of the left foot were performed. It cannot be verified that at least 3 views were taken. In addition, the medical record states that a split was placed, but there is no mention of fiberglass cast supplies.   Based on this information, we decided that Medicare rules for coverage of CPT codes 73630-LT and Q4046 have not been met.Therefore, we decided that the Plan does not have to pay forCPT codes 73630-LT and Q4046 billed for date of service June 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to payforthe skilled nursing facility (SNF) services provided to the enrollee from March 10, 2019 to April 8, 2019.You asked the Plan to pay forthe SNF services. You say that  The Plan denied your request. The Plan says that there was no daily skilled nurse or therapist need.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 pay for the SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found that the enrollee's conditiondid not meet Medicare criteria for SNF services.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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided to the enrollee from March 10, 2019 to April 8, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on July 29, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you disagree with the increase of 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection provided on July 29, 2019. The allowed amount is $819.90 and 20% of that is $163.98.You have been asked to pay the total coinsurance amount of $163.98 for a Medicare Part B drug injection. A Medicare Part B drug 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 a Medicare Part B drug injection provided on July 29, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided from May 24, 2019 through May 26, 2019.You asked the Plan to waive the copayment for the ED visit. You say that you were admitted to the hospital. You say that you should not have to pay 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 $90 copayment for emergency care.You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were admitted to outpatient observation. 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 ED visit provided from May 24, 2019 through May 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay separately for services provided on September 4, 2019.You asked the Plan to pay separately for the ambulance services. You say that the ambulance services were medically necessary.The Plan denied your request. The Plan says ambulance services used for the transport of a hospital inpatient to another facility for services is not separately payable.Medicare does not pay separately for ambulance services when the enrollee is in inpatient status. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee was inpatient from September 1, 2019 to September 6, 2019. 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 separately for services provided on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from August 11, 2019 to August 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plansays 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 forthe home infusion therapy rendered to from August 11, 2019 to August 18, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided by from July 26, 2019 to October 14, 2019.You asked the Plan to pay for diabetic supplies. You say that you are appealing with additional information.The Plan denied your request. The Plan says the denial of payment for these items is correct, because the delivery ticket did not include a tracking number nor did the proof of delivery include an order number to corroborate the delivery ticket submitted.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier must corroborate the documentation in the medical record and confirm that coverage criteria have been met. The rules say that the supplies must furnish to the Plan sufficient information to determine whether payment is due.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of diabetic supplies have not been met.The claim billed is not corroborated by the documentation submitted. Namely, the delivery ticket submitted is not corroborated by the delivering carrier's tracking sheet. Therefore, you have not submitted sufficient information to the Plan to justify payment of this claim. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided from July 26, 2019 to October 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe ED and inpatient stay provided from September 21, 2019 through September 26, 2019.You asked the Plan to waive the copayments forthe ED visit and inpatient stay. You say that the provider did not advise you of any copayments. You say thatthe copayments should be waived.The Plan denied your request. The Plan says the copayments 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 $90 copayment per visit for emergency care. The copayment is not waived if admitted to inpatient hospital.Your contract with the Plan clearly says that you must pay a $290 copayment per day for days 1-6 per admission.The day before you are discharged is your last inpatient day.You have been asked to pay a total of $1,250 for the ED visit and inpatient stay. Date of ServiceServiceStandard CopaymentMember LiabilitySeptember 21, 2019ED Visit$90$90September 22, 2019-September 26, 2019Inpatient Stay$290/day$1,160TOTAL:$1,250
The ED visit falls within the "Emergency care" benefit category. The 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 copayments forthe ED and inpatient stay provided from September 21, 2019 through September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) services provided on July 15, 2019 by out of network provider.
You asked the Plan to pay for the MRI services. You say that the records provided support the medical necessity of the services in dispute. The Plan denied your request. The Plan says the non-emergent services were provided out-of-network without prior authorization. The Plan says that there were multiple diagnostic radiologists within 25 miles of the enrollee's home that could have supplied the services in dispute.
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 could have provided the MRI 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 magnetic resonance imaging (MRI) services provided on July 15, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formoderate sedation services (99152) provided June20, 2019 to June 26, 2019.You asked the Plan to pay formoderate sedation services. You say that you would like reconsideration based on the medical records provided.The Plan denied your request. The Plan says the billed services are 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.We asked our coder 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 moderate sedation services. Our reviewer says that code 99152 is not supported by the medical records provided. Our coder reviewer found the medical records provided do not include documentation of Moderate sedation services provided by the same coder 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 being performed on June 20, 2019. Therefore the service cannot be validated.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay formoderate sedation services (99152) provided June 20, 2019 to June 26, 2019