Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the cost share for the professional service (96372) on July 9, 2019. We decided that the Plan does not have to waive the cost share for the laboratory work, the specialist office visit, the Part C drugs, and the professional services from July 9, 2019 to August 22, 2019.You asked the Plan to waive the cost share for the professional service (96372) on July 9, 2019. You say that this is creating a financial hardship because you are on a fixed income.The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to waive the cost share forthe professional service(96372) on July 9, 2019. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The record shows you were charged the full amount for the specialist office visit on July 9, 2019. The professional service is covered under the specialist office visit copayment. Therefore, you are not responsible for the cost share amount for the professional service.The Plan says that you must pay $3.18 for the professional service (96372). Based on the plan contract, however, you cannot be asked to pay more than $0 for the professional service (96372). Therefore, we decided that the Plan has to reduce the cost share for the professional service from $3.18to $0. We also decided that the Plan does not have to waive the cost share for the laboratory work, the specialist office visit, the Part C drugs, and the professional servicesfrom July 9, 2019 to August 22, 2019.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 a $15 copayment for in-network laboratory services performed by a provider other than your primary care physician. The Plan contract clearly says that you must pay a $30 copayment for specialist services, including doctor's office visits.The Plan contract clearly says that you must pay 20% coinsurance for the Part C drugs. Therefore, we decided that the Plan does not have to waive the cost share for the laboratory work, the specialist office visit,the Part C drugs, and the professional services from July 9, 2019 to August 22, 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 the medical services provided on September 14, 2018 by an out of network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The 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 September 14, 2018 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee on June 16, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee was seen at hospital in the emergency department and was then admitted to the intensive care unit as inpatient from June 16, 2019 to June 17, 2019. Therefore, the enrollee was asked to pay a $285 copayment for the inpatient hospital care. 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 copayment for inpatient hospital care provided to the enrollee on June 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 the enrollee by an out-of-network provider on February 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99220) provided to the enrollee on June 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says another observation service was reported for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that contractors pay for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care. We looked at the file and Medicare rules. There is no evidence in the documentation provided that the physician was the physician who ordered observation services, or was the physician responsible for the enrollee's care. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99220) provided to the enrollee on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on February 5, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you would like reconsideration as you are unable to pay the $30 copayment. The Plan denied your request. The Plan says per the EOC; you are responsible for a $30 copayment for a specialist office visit.
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 $30 copayment for Physician/Practitioner services. You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner 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 a specialist office visit provided on February 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.You asked the Plan to waive the copayment for the ambulance services. You say that after being released facility, you had no family or friends to pick you up so the facility called for an ambulance to transport you home.The Plan denied your request. The Plan says you were charged this cost sharing 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 $225 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $225 for these 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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the 10% coinsurance charged for injections provided during outpatient surgery on May 30, 2019. You asked the Plan to waive this cost share. You say that you do not believe this bill is correct. The Plan denied your request. The Plan says this coinsurance was charged based on the injections provided and the plan contract agreement. 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 10% coinsurance for Medicare Part B administered drugs. 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 10% coinsurance charged for injections provided during outpatient surgery on May 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the nuclear imaging services provided on April 9, 2019..You asked the Plan to pay for the OON imaging services. You say that this claim should be paid due to medical necessity.The Plan denied your request. The Plan says this OON care was not emergent or urgently needed and was available from network providers. No authorization was requested for this care as is required.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 nuclear imaging services provided on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on June 27, 2019.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 rendering 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 physician services provided on June 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the resin-based composite - 4 or more surfaces and
resin-based composite - 2 posterior surfaces provided on January 3, 2019.
You asked the Plan to pay more for the resin-based composite - 4 or more surfaces and resin-based composite -
2 posterior surfaces. You say that you had these services because you had missing teeth. The Plan denied your
request. The Plan says benefits for these services have been satisfied and the frequency limitation has been
exceeded.
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, restorations are limited to two
procedures per calendar year. The record shows that you received 2 resin-based composites on January 3, 2019
and your restorations benefit was then exhausted. Therefore, we decided that the Plan does not have to pay
more for the resin-based composite - 4 or more surfaces and resin-based composite - 2 posterior surfaces
provided on January 3, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services provided on March 18 to May 20, 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 provider is not eligible for Medicare payment.The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors are not eligible for enrollment in the Medicare Program. We looked at the file and Medicare rules.The provider is a Licensed Professional Counselor. LPC's are not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient mental health services provide March 18 to May 20, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from July 13, 2018 through July 25, 2018.You asked the Plan to pay for SNF 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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 care have not been met.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from July 13, 2018 through July 25, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periapical x-rays provided on August 8, 2019.You asked the Plan to pay forthe periapical x-rays. You say that you cannot afford to pay for it.The Plan denied your request. The Plan says that your plan does not provide a benefit for this type of service.Medicare generally does not cover dental services.However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not amongthose covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe periapical x-rays provided on August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided by "the provider" on July 29, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you disagree with the copayment amount owed.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgeryreceived in an ambulatory surgical center. Review of the file shows you received a colonoscopy on July 29, 2019. The colonoscopy you received was considered a diagnostic colonoscopy and not a screening colonoscopy. Therefore, the colonoscopy is subject to the outpatient surgical copayment.You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the outpatient surgery 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 colonoscopy provided by "the provider" on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an influenza vaccine (90471 and 90658) provided by the provider on August 27, 2019.You asked the Plan to pay for the influenza vaccine. You say that receiving the shot from this provider was more convenient and assured you that you were getting the right shot. The Plan denied your request. The Plan says the provider is a Medicare voluntary Opted-Out provider.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation.. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for an influenza vaccine (90471 and 90658) provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 4, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The drug testing services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 or 3 view spinal x-ray (72100) and a 2 or 3 view hip x-ray (73502).
You asked the Plan to pay for the spine and hip x-rays. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include the number of views per x-ray, therefore, the billed service cannot be verified.
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 72100 is radiologic examination, spine, lumbosacral; 2 or 3 views. The CPT Code Manual definition of code 73502 is radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views.
We find that CPT codes 72100 and 73502 are not supported in the record. Specifically, the record does not specify the number of views per x-ray. Based on this information, we decided that Medicare rules for coverage of the spine and hip x-rays have not been met. Therefore, we decided that the Plan does not have to pay for 2 or 3 view spinal x-ray (72100) and a 2 or 3 view hip x-ray (73502).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 14, 2019 to July 2, 2019 by the out-of-network provider.
You asked the Plan to pay for the out-of-network. You say that the provider was unaware that he was out-of-network with the enrollee's plan. The Plan denied your request. The Plan says the enrollee's plan requires the utilization of network providers, and authorization for certain 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 file shows that the enrollee was seen for a routine check-up and follow-up. 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 out-of-network services. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 14, 2019 to July 2, 2019 by the out-of-network provider.