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

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on
January 14, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not aware that
you would owe a coinsurance. 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 on January 14, 2020. The allowed amount is $125 and 20% of that is $25.
You have been asked to pay the total coinsurance amount of $25 for a Medicare Part B drug. A Medicare Part
B drug 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 provided on January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 12,
2020.
You asked the Plan to waive the copayment for ambulance services. You say that the ambulance took you to
the wrong hospital and 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 $125
copayment for ambulance services.
You have been asked to pay a $125 copayment for ambulance services. Ambulance services fall within the
ambulance 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 copayment for ambulance services
provided on May 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an injection and ophthalmology services
provided on June 23, 2020.
You asked the Plan to waive the cost-sharing for injection and specialist services. You say that you were not
charged this amount on previous claims. The Plan denied your request. The Plan says the cost-sharing amounts
you are being charged are 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 20%
coinsurance for injection and $35 copayment for specialist services. The allowed amount of the injection is
$94, resulting in a coinsurance amount of $18.80. Your total cost-sharing responsibility is therefore $53.80.
You have been asked to pay 20% coinsurance for injection and $35 copayment for specialist services. Injection
and specialist services fall within the "Medicare Part B Prescription Drugs" and "Physician/Practitioner
Services, including Doctor's Office Visits" benefit categories. 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 cost-sharing
for an injection and ophthalmology services provided on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit (99215) on September
3, 2020.
You asked the Plan to waive the copayment for an urgent care visit. You say that you feel you paid more than
you should have for these services. The Plan denied your request. The Plan says the correct copayment was
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 $15
copayment for Medicare-covered urgently needed services.
You have been asked to pay a $15 copayment for an urgent care visit. An urgent care visit falls within the
"Urgently needed 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 copayment for an urgent
care visit (99215) on September 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from August 6, 2020, through August 11, 2020, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that there is no way to obtain prior authorization when the provider does not know what patient they will service. The Plan denied your request. The Plan says no authorization was obtained and the services rendered were not urgent or emergent 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 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 from August 6, 2020, through August 11, 2020, by an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services
rendered on July 11, 2020 to July 12, 2020.
You asked the Plan to waive the copayment for these services. You say that you shouldn't have to pay the
copayment because you had to go to the ER due to pain. The Plan denied your request. The Plan says the
copayment was 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 $120
copayment for Medicare-covered emergency care visits.
Review of the file shows that you received ER services from July 11, 2020 to July 12, 2020. You have been
asked to pay a $120 copayment for these services. These services fall within the Medicare-covered emergency
care visits benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER)
services rendered on July 11, 2020 to July 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cytopathology laboratory service (88175)
provided on July 15, 2020.
You asked the Plan to waive the copayment for a cytopathology laboratory service. You say that this should be
fully covered as a preventative service. The Plan denied your request. The Plan says this processed 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 $15
copayment for laboratory services.
You have been asked to pay a $15 copayment for a cytopathology laboratory service. 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 cytopathology laboratory service (88175) provided on July 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you tested positive for COVID-19 and need to
be in isolation. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 pre-approve SNF admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled
professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a
Skilled Nursing Facility (SNF) setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided from February 17, 2020,
through March 2, 2020, by an out-of-network provider.
You asked the Plan to pay for the acupuncture services. You say that you are requesting reimbursement of
services rendered. The Plan denied your request. The Plan says the Medicare rules have not been met.
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. 
Review of the file show that you received acupuncture services from February 17, 2020, through March 2,
2020, by an out-of-network provider. Certain acupuncture services are covered by Medicare. Furthermore, the
provider is not in-network with the Plan. Therefore, we decided that the Plan does not have to pay for the
acupuncture services provided from February 17, 2020, through March 2, 2020, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forduplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT Code 93976) provided on August 28, 2020.You asked the Plan to pay forthe services. You say that you would like reconsideration because this service was billed correctly.The Plan denied your request. The Plan says this claim was submitted with a place of service that does not match the member's correct inpatient status.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The services were denied because payment is not allowed for this claim because the place of service billed doesn't match other claims for the same date of service. Specifically, the record indicates that this member was registered inpatient on the billed date of service. This claim was submitted with place of service code 22 for on campus-outpatient hospital. This is not an appropriate place of service code. A corrected claim can be submitted to the claims address on the back of the member's ID card with the appropriate place of service for claim reconsideration. The member is not responsible for payment.Therefore, we decided that the Plan does not have to pay forduplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study (CPT Code 93976) provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) performed on September 1, 2020.
You asked the Plan to pay for an eye refraction. You say that although you signed a financial waiver form you
had no idea what you were signing. The Plan denied your request. The Plan says rules for payment have not
been met.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers an annual routine eye exam.
We looked at the file and the Plan's rules. In this case, the provider has documented that you have signed a
financial waiver form accepting liability for denied services. Based on this information, we decided that the
Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not
have to pay for an eye refraction (92015) performed on September 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approachto rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupationaltherapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed with a Group 1 support surface.You asked the Plan to pre-approvethe semi-electric hospital bed and support surface. You say that these items are necessary for the patient's health.The Plan denied your request. The Plan says there is no documentation of the criteria being met. The Plan must follow Medicare rules. Medicare rules say that semi-electric hospital beds and Group 1 support surfaces may be covered when the above criteria are met. Review of the file finds record of one visit from September 17. 2020. This visit documents falling out of bed. There is no documentation of requirements of positioning of thebody or special attachments. There is no need for frequent or immediate changes in body position described. In addition, the record does not show that the patient is completely immobile or has limited mobility causing an inability to alleviate pressure. There is no documentation of any stage pressure ulcer. Based on this information, we find that the coverage criteria for the requested hospital bed and Group 1 support surface are not met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed with a Group 1 support surface.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from May 29, 2020, to May 30, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you did not have any control over what was performed during the procedure. You also say that you were told that you could only take drugs supplied by the medical center. The Plan denied your request. The Plan says you were in an outpatient setting, and Medicare nor the Health Plan cover self-administered drugs in the outpatient setting under Medicare Part B.
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 self-administered drugs provided from May 29, 2020, to May 30, 2020.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and an EKG provided by a
participating provider on September 9, 2020.
You asked the Plan to waive the copayment for an office visit and an EKG. You say that this should only be
one copayment. You say that both of these services were provided in one visit. The Plan denied your request.
The Plan says the correct copayments have 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 $10
copayment for physician/practitioner services/in-network/PCP and outpatient diagnostic tests/innetwork/simple diagnostic test.
You have been asked to pay a $10 copayment for an office visit and an EKG. The total amount you are being
asked to pay is $20 ($10 + $10 = $20). When additional services are provided during and office visit, additional
copayments are applied; therefore, the correct copayments have been applied. An office visit falls within the
physician/practitioner services/in-network/PCP benefit category and an EKG falls within the outpatient
diagnostic tests/in-network/simple diagnostic test 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 office visit and an EKG provided by a participating provider on September 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services (CPT 81001 and CPT 85025) provided to the enrollee on May 15, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says there is no additional documentation supporting additional studies which were billed and remain denied.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 the denied codes is:CPT 81001:Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopyCPT 85025:Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC countWe asked our coding 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 the services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation does not meet the criteria for payment of additional units beyond one unit each, which was paid to the provider, by the health plan. The medical records provided do not include sufficient documentation to support billing additional units of 81001 or 85025, therefore these services cannot be verified.
We looked at this coder'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 forlaboratory services (CPT 81001 and CPT 85025) provided to the enrollee on May 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for ambulance services provided.

You asked the Plan to waive the co payment for ambulance services. You say that you were experiencing an emergency and had no choice on transportation.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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co payment for ambulance services.

You have been asked to pay a $295 co payment for ambulance services. Ambulance services fall within the ambulance 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 co payment for ambulance services provided.