Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the stress test rendered to you on June 6, 2019.You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges.The Plan denied your request. The Plan says the coinsurance 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 10% coinsurance, not to exceed $75 in a single day for each Medicare-covered other diagnostic test. Review of the file shows that you received a stress test on June 6, 2019. You have been asked to pay a 10% coinsurance for these services. These services fall within the Medicare-covered other 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 coinsurance for the stress test rendered to you on June 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract surgery rendered to you on August 29, 2019.You asked the Plan to waive the copayment for these services. You say that you disagree with the charges.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 $250 copayment for each ambulatory surgical center visit. Review of the file shows that you received cataract surgery on August 29, 2019. You have been asked to pay a $250 copayment for these services. These services fall within the ambulatory surgical center visit 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 cataract surgery rendered to you on August 29,2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe oxygen provided from July 7, 2019 to September 7, 2019.You asked the Plan to waive the coinsurance forthe oxygen. You say that you believed the plan paid this at 100%.The Plan denied your request. The Plan says that you are responsible for the coinsurance.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 Durable medical equipment (DME) and related supplies. You have been asked to pay 20% coinsurance for the oxygen. The oxygenfalls within the Durable medical equipment (DME) and related 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 coinsurance forthe oxygen provided from July 7, 2019 to September 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridement provided on July 5, 2019.You asked the Plan to waive the copayment forwound debridement. You say that this was a wound procedure. You say that this should fall under a specialist office visit.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 $290 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay a $290 copayment for wound debridement. Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Wound debridement is considered a surgical procedure. 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 forwound debridement provided on July 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the stem cell therapy provided by out of network provider.
You asked the Plan to reimburse you for the laboratory services. You say that the Plan should pay for the stem cell service since it prevented you from having to have both knees replaces and the Plan would have had to pay for those surgeries. You say that this service has improved your condition by over 80% and will be 100%. The Plan denied your request. The Plan says the services you received could have been provided in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this 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 reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the stem cell therapy provided by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided.
You asked the Plan to pay for these drugs. You say that plan materials do not state that these drugs are not covered. The Plan denied your request. The Plan says that this is not covered by Medicare.
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.
Benefits for these 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 pay for the medical services provided by out of network provider.
You asked the Plan to pay for chiropractic services. You say that you were unaware that you needed prior authorization for these services. The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay 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 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services received from January 3, 2019 to February 21, 2019.You asked the Plan to waive the copayment for the services. You say that this service should be coded differently.The Plan denied your request. The Plan says the claims were processed appropriately according to your benefits and the services rendered.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 $400 copayment for outpatient hospital services. You have been asked to pay a $196.81 for the visits on 1/10/19, 1/24/19, and 1/31/19, and a $184.70 copayment for the visits on 2/14/19 and 2/21/19. There is normally a $400 copayment for each of these services, but the allowed amounts for all the visits were less than that. The 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 copayment for outpatient hospital services received from January 3, 2019 to February 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 20, 2019 by out of network provider, "the doctor".You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 medical services provided on June 20, 2019 by out of network provider, "the doctor".
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with lesion removal provided on August 10, 2018.You asked the Plan to waive the copayment for the colonoscopy. You say that the procedure room was a supply room. You say that you should not have to pay for the unsanitary procedure and recovery room.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 $275 copayment for outpatient surgery at an in-network ambulatory surgical center.You have been asked to pay a $275 copayment for the colonoscopy. The colonoscopy 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 the colonoscopy with lesion removal provided on August 10, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy provided from December 13, 2018 through March 21, 2019.
You asked the Plan to waive the copayments for physical therapy. You say that you were informed there would be no copayment. 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 $40 copayment for Medicare-covered in-network physical therapy.
You have been asked to pay a total of $950 for physical therapy. Physical therapy falls within the "Outpatient rehabilitation 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 copayments for physical therapy provided from December 13, 2018 through March 21, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the ear mold/inserts provided by participating provider on July 10, 2019.You asked the Plan to pay for the ear mold/inserts. You say that the Plan told you the ear molds may be covered under your DME benefit.The Plan denied your request. The Plan says that ear mold/inserts are not covered by Medicare or the Plan.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.You were referred for the ear mold/inserts. The physician is a contract provider. The file does not show that the plan provided notice that the ear mold/inserts would not be covered. Under Medicare rules, this means the ear mold/inserts is considered approved by the plan.Therefore, we decided that the Plan has to pay,less any coinsurance and sales tax, for the ear mold/inserts provided on July 10, 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 waive the coinsurance for denosumab injections (J0897 and 96372) provided on February 12, 2019 to March 12, 2019.
You asked the Plan to waive the coinsurance for denosumab injections. You say that you have never had to pay such a large amount. The Plan denied your request. The Plan says this processed correctly according to your 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 Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for denosumab injections. Denosumab injections 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 denosumab injections (J0897 and 96372) provided on February 12, 2019 to March 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe portable oxygen concentrator provided on March 28, 2018 by the out of network provider.You asked the Plan to reimburse you forthe durable medical equipment (DME). You say that you were not aware authorization was required for an oxygen tank.The Plan denied your request. The Plan says authorization was not obtained before the item was supplied to you.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to reimburse you for care from out-of-network providers only in casesinvolving emergencies, out of area urgent care and pre-approved care.The 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 reimburse you for these items/services.Therefore, we decided that the Plan does not have to reimburse you forthe portable oxygen concentrator provided on March 28, 2018 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for knee x-rays (73560 and 73565) provided on July 5, 2019.You asked the Plan to pay for the knee x-rays. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 73560, was denied because it is a column II procedure to the column I procedure, 77073.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, we have confirmed that code the knee x-rays has a bundled relationship with code 73560 and 73565 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for knee x-rays (73560 and 73565) provided on July 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided January 30, 2019 to January 31, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.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 documentation in the medical records does not support a diagnosis of acute coronary syndrome. The enrollee's symptoms were deemed to be non-cardiac in origin. It was not reasonable to expect that this enrollee's necessary hospital care would span two midnights.We looked at this physician's review, the file, andMedicare 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 forthe acute inpatient hospital care provided January 30, 2019 to January 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99497) provided August 12, 2018.You asked the Plan to pay for the physician services. You say that services were medically necessary and properly billed.The Plan denied your request. The Plan says the claim was not submitted timely.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 physician services was not filed until August 30, 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 physician services (99497) provided August 12, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe upper and lower dentures (D5130, D5140) provided by the provider on August 15, 2019.You asked the Plan to pay forthe upper and lower dentures (D5130, D5140). You say that you were led to believe that they dentures would have 30% coverage. You say you were not told the benefits would change from 2018 to 2019. The Plan denied your request. The Plan says these services are not covered 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, the upper and lower dentures (D5130, D5140) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay forthe upper and lower dentures (D5130, D5140) provided on August 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided to the enrollee on November 28, 2018 and billed under codes 80307 and G0481. You asked the Plan to pay forthis service. You say that this claim should be paid. The Plan denied your request. The Plan says the medical records provided do not support the services billed. The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on November 28, 2018 and billed under codes 80307 and G0481.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy provided from August 7, 2018 to December 4, 2018.You asked the Plan to pay for home infusion therapy. You say that the Plan should pay this claim.The Plan denied your request. The Plan says this procedure code is not payable by Medicare.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.We find that CPT code S9328 is not covered by Medicare. Specifically,S codes are unique temporary codes established for private pay or use, they are not valid nor payable by Medicare. 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 provided from August 7, 2018 to December 4, 2018.