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

We decided that the Plan does not have to waive the cost-sharing for the services from November 8, 2019
through January 3, 2020 provided by an in-network provider.
You asked the Plan to waive the cost-sharing for the services. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claims were
processed accordingly with your 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).
From November 8, 2019 to November 9, 2019 you received inpatient mental health care for a total of 1 day.
You are responsible for a copayment of $395 copayment each day for days 1 to 4 for inpatient mental health
care. You were correctly assessed a copayment of $395.00.
You were then discharged from inpatient mental health care and admitted for inpatient hospital care.
From November 9, 2019 to December 31, 2019 you received inpatient hospital services for a total of 52 days.
You are responsible for a copayment amount of $395 a day for days 1 to 4 for inpatient hospital care. You
should have been assessed a copayment amount of $1,580.00 ($395 x 4 days) however, you reached you outof-
pocket maximum with the processing of this claim and were only assessed a copayment of $854.66.
You were discharged from inpatient hospital care and admitted for inpatient mental health services.
From December 31, 2019 to January 3, 2020 you received inpatient mental health care for a total of 3 days.
You are responsible for a copayment of $395 copayment each day for days 1 to 4 for inpatient mental health
care. You were correctly assessed a copayment of $1,185.00 ($395.00 x 3 days). This claim was processed
prior to the claim for November 9. 2019 to December 31, 2019 and was included in your out-of-pocket
maximum total. 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 the services from November 8,
2019 through January 3, 2020 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 21, 2019 through December 31, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 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). Review of the file shows that you were admitted on December 21, 2019 and discharged on December 31, 2019. You were asked to pay a $285 copayment per day from December 21, 2019 through December 27, 2019, days 1-7 of your inpatient stay. There were no copayment charges from December 28, 2019, day 8 of your inpatient hospital care until your day of discharge December 31, 2019. Per your contract there is a $285 copayment per day required for days 1-7. 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 inpatient hospital care from December 21, 2019 through December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346), four gingival irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use (D9630) provided on January 9, 2020 by an OON provider. 
 
You asked the Plan to pay for the scaling in presence of generalized moderate or severe gingival inflammation, gingival irrigations, and drugs or medicaments dispensed in the office for home use. You say that you called the Plan prior to receiving the services and were told that this provider was in-network. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that these services are not listed as 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 requested items or services are not among those covered under this benefit. The contract also clearly states that services provided by an OON provider are not covered. Therefore, we decided that the Plan does not have to pay for the scaling in presence of generalized moderate or severe gingival inflammation (D4346), four gingival irrigations (D4921 x4), and drugs or medicaments dispensed in the office for home use (D9630) provided on January 9, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services from February 3, 2020 through February 8, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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).  
 
Review of the file shows that you received emergency and then you were admitted for inpatient hospital care on February 3, 2020 and discharged on February 8, 2020. You were asked to pay a $90 copayment for emergency care. Furthermore, you were asked to pay a $210 copayment per day from February 3, 2020 through February 7, 2020, days 1-5 of your inpatient hospital care. You were discharged on February 8, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $210 copayment per day required for days 1-6 and a $90 copayment for emergency care. 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 services from February 3, 2020 through February 8, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for a sleep study (95810) provided on January 16, 2020.You asked the Plan to pay fora sleep study. You say that this service was authorized.The Plan denied your request. The Plan says that the authorized service was previously billed and paid.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. This claim was billed with modifier TC for the technical component of the sleep study. The submitted documentation does not show that the technical component of this service has been paid, and the medical records support that this study took place on the billed date of service.Therefore, we decided that the Plan has to pay fora sleep study (95810) provided on January 16, 2020.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 4, 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on May 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 23, 2020.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the soft tissue neck (70491) provided on March 11, 2020 by the provider. 
 
You asked the Plan to pay for the CT scan of the soft tissue neck. You say that you should not be responsible for the charge. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $235 copayment for CT scans.  
 
You have been asked to pay $235 for the CT scan of the soft tissue neck. 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 pay for the computed tomography (CT) scan of the soft tissue neck (70491) provided on March 11, 2020 by the provider.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee exceeds the mobility criteria for admission.
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 the admission. 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. You do not require skilled nursing or therapy services on a daily basis. You do 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 the 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 services provided to the enrollee on January 22,2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must first be submitted to the primary insurer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the enrollee's primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that your current chair hurts your back. The Plan denied your request. The Plan says that there is no documentation stating that this is medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power wheelchair. Our reviewer says that a power wheelchair is not medically reasonable and necessary. There is no documentation to support that you have a personal mobility deficit that impairs participation in MRADL. There is no documentation that you are unable to move the current chair in your home, bedroom or bathrooms and that your mobility deficit be helped by the use of a walker, cane or manual wheelchair. There is no functional evaluation to assess your ability to safely operate a power mobility device. Our physician reviewer found that your condition does not meet Medicare criteria for a power wheelchair. 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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for PT/INR testing (G0249) billed for December 31, 2019.
You asked the Plan to pay for the PT/INR testing. You say that you would like reconsideration because this code has no frequency limitations. The Plan denied your request. The Plan says this code has a frequency limitation of no more than one unit per 25 days which has been exceeded.
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 G0249 is provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests. We find that CPT code G0249 is not supported in the record. Specifically, the record indicates that this supply was billed and paid for on December 16, 2019. As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare.
Based on this information, we decided that Medicare rules for coverage of the PT/INR testing have not been met. Therefore, we decided that the Plan does not have to pay for PT/INR testing (G0249) billed for December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility care (99308) provided on January 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON nursing facility care. You say that these services were medically necessary and provided in good faith.The Plan denied yourrequest. The Plan says these services were not authorized.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 nursing facility care (99308) provided on January7, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit (87040, 99284, 71045, 93005) provided February 26, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that the copayment should be waived.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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 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.Therefore, we decided that the Plan does not have to waive the copayment foran emergency room visit (87040, 99284, 71045, 93005) provided February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit received on March 30, 2020.You asked the Plan to waive the copayment for the visit. You say that you did not have a service done on this date.The Plan denied your request. The Plan says the copayment was applied correctly 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 $35 copayment for specialist office visits. You have been asked to pay a $35 copayment for the visit. The visit falls within the specialist office 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 a specialist office visit received on March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 drug testing services provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on March 12, 2020.
You asked the Plan to waive the copayment for the eye exam. The Plan denied your request. The Plan says the
claim processed with the correct copayment.
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 $40
copayment for Medicare-covered vision care.
You have been asked to pay $40 copayment for the eye exam. the eye exam falls within the Medicare-covered
vision care benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye exam provided on
March 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation, bitewings, and panoramic x-ray provided on January 9, 2020.You asked the Plan to pay forthe comprehensive oral evaluation, bitewings, and panoramic x-ray. You say that you contacted the Plan prior to receiving these services and were advised that you could receive dental services from these providers.The Plan denied your request. The Plan says these providers opted out of the Medicare program from February 10, 2016 to February 10, 2022. The Plan also says that the Plan cannot make payment for services performed by providers who have opted out of the Medicare program.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 by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. The records show that no calls were received from you prior to the date of service regarding your dental benefits.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation, bitewings, and panoramic x-ray provided on January 9, 2020.Your complaint about being misled by the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.