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

We decided that the Plan does not have to pay forthe outpatient mental health services (90837, 90791) provided on December 16, 2019.You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network providers available.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 forthe outpatient mental health services (90837, 90791) provided on December 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordermatology services provided on October 29, 2019 by an out of network (OON) provider.You asked the Plan to pay fordermatology services. You say that you needed to see a good reliable dermatologist. You say that this bill is a financial burden because your income is very low.The Plandenied your request. The Plan says there are in-network providers available for these 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.  Please contact the Plan for a list of in-network providers available. 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 fordermatology services provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 22, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray of the hip billed with CPT code 73521 for date of service
December 3, 2019.
You asked the Plan to pay for the x-ray. You say that the x-ray was denied in error and that the clinical
documentation provided supports the CPT code billed. The Plan denied your request. The Plan says that two or
more diagnosis codes associated to the CPT code in dispute are mismatched per the ICD-10-CM Official
Guidelines for Coding and Reporting
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan states that some ICD-10-CM codes indicate laterality,
specifying whether the condition occurs on the left, right or is bilateral. The Plan says that it is not appropriate
to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available.
However, that language does not appear in the ICD-10 CM Official Guidelines. These cited guidelines which
the Plan used to support their denial do not say that, if the enrollee has a bilateral condition, then it is not
appropriate to use the two lateral diagnosis codes which were billed. While it may be better to use the M16.0
diagnosis code for bilateral osteoarthritis of the hip, there is nothing saying that the claim is not payable solely
because the diagnosis codes are separated. While the Plan can deny the claim for a bilateral procedure without
a bilateral diagnosis, upon appeal the provider can support that the service billed was provided. In this case, the
documentation provided does support that the enrollee had a bilateral x-ray for which bilateral osteoarthritis
was found. The Plan has not substantiated their denial reason. Therefore, we decided that the Plan has to pay
for an x-ray of the hip billed with CPT code 73521 for date of service December 3, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to enrollee from October 1, 2019 to October 30, 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 claims were not billed correctly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The claims were not billed with a valid TOB 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 enrollee from October 1, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (93306) and cardiovascular stress test using a maximal or submaximal treadmill (93015).
You asked the Plan to pre-approve a TTE and cardiovascular stress test using a treadmill. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a TTE and cardiovascular stress test using a treadmill. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records the enrollee has some cardiac risk but no documented symptoms suggestive of an acute cardiac condition and no objective findings of an acute cardiac condition by physical exam or electrocardiogram. The enrollee's pain is documented as chest wall pain due to costochondritis without documented concern for another cause. In this circumstance the documentation does not support the medical necessity for the tests in the appeal. Coverage criteria are not met since there is no documented covered indication for the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a TTE and cardiovascular stress test using a treadmill have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography (TTE) (93306) and cardiovascular stress test using a maximal or submaximal treadmill (93015).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on October 25, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you disagree with the increase in charges.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. The enrolleereceived a Medicare Part B drug on October 25, 2019. The allowed amount is $6,136.40 and 20% of that is $1,227.28. The enrollee has been asked to pay the total coinsurance amount of $1,227.28 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code 99497 provided on October 6, 2019.
You asked the Plan to pay for CPT code 99497. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan says an approved authorization already exists; however, either the service performed, the servicing provider, or the number of visits billed do not match what was approved on the authorization. The Plan says they denied payment for CPT code 99497 for one of the above reasons listed. The Plan was unable to make a final determination within the allotted time frame. The case file the Plan sent is incomplete, as there is no authorization document provided to verify what services were authorized by the Plan. We find the Plan has not substantiated their reasoning for denial based on Medicare guidelines. Therefore, we decided that the Plan has to pay for CPT code 99497 provided on October 6, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an epidural injection (64483) provided on October 15, 2019.
You asked the Plan to pay for the epidural injection. You say that you would like reconsideration because this code was billed bilaterally. The Plan denied your request. The Plan says not enough information has been provided to determine how the member came to the servicing provider or whether the services were medically necessary.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the epidural injection have not been met. Specifically, the record does not include any medical records to verify or determine the medical necessity of the services billed. Therefore, we decided that the Plan does not have to pay for an epidural injection (64483) provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December 21, 2019.You asked the Plan to waive the copayment for the urgent care visit. You say that you left without being seen. You say that you should not be charged.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 $15 copayment per visit for in-network urgently needed care.You have been asked to pay a $15 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show that you were examined and treatment was advised. 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 urgent care visit provided on December 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hysteroscopy (58558) provided on October 29, 2019 and physical therapy services (97140, 97110, 97530) provided on October 28, 2019.
You asked the Plan to waive the copayment for a hysteroscopy and physical therapy services. You say that these services should be paid in full because you were referred by your primary care physician. The Plan denied your request. The Plan says these services 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 $210 copayment for outpatient surgery and a $40 copayment for physical therapy services. You have been asked to pay $210 for a hysteroscopy, which is an outpatient surgery, and $40 for physical therapy services. 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 hysteroscopy (58558) provided on October 29, 2019 and physical therapy services (97140, 97110, 97530) provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on July 19, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on July 19, 2019. The allowed amount is $1,914.73 and 20% of that is $382.95. You have been asked to pay the total coinsurance amount of $382.95 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 thatthe Plan does not have to waive the coinsurance fora Medicare Part B drug provided on July 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on November 28, 2019.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that the claim processed accordingly.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 $310 copayment for Medicare-covered one-way ambulance benefit per segment. You have been asked to pay a $310 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way ambulance benefit per segment 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 forthe ambulance transport provided on November 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on January 3, 2020.
You asked the Plan to waive the copayment for lab test. You say that this lab test should have been submitted as a single bill with the office visit you had. 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 $50 copayment for in-network specialist lab services. You have been asked to pay the allowed amount of $47.44, which is less than the $50 copayment for lab test. Lab test falls 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 copayment for laboratory testing provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on November 13, 2019.You asked the Planto waive the copayment forthe colonoscopy. You say that your plan indicates a colonoscopy is covered with no copayment. You say that it may have been billed as diagnostic instead of screening.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 $260 copayment for a diagnostic colonoscopy at an in-network outpatient hospital. You have been asked to pay a $260 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a diagnostic colonoscopy was performed. 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 forthe colonoscopy provided on November 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) services rendered to you on August 28, 2019.You asked the Plan to waive the copayment forthese services. You say that your insurance card says there is a $0 copayment.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 Partial Dual Eligible members for emergency care. Review of the file shows that you received ER services on August 28, 2019. You have been asked to pay a $120 copayment for these services. These services fall within the emergency 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. The $0 cost sharing is for Full Dual Eligible plans, and the file shows that you are not enrolled in this plan option. Therefore, we decided that the Plan does not have to waive the copayment forthe emergency room (ER) services rendered to you on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the iron infusions provided from September 10, 2019 to September 14, 2019.You asked the Plan to waive the copayments for the iron infusions. You say that you believe the infusions should be covered because you cannot take iron by mouth and you have never had to pay for the infusions before. 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 $305 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $305 copayment for the iron infusions in an outpatient hospital.You have been asked to pay a $177.80 copayment for each of the iron infusions. The iron infusions fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the iron infusions are considered physician services that were received at an outpatient hospital.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the iron infusions provided from September 10, 2019 to September 14, 2019.