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

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 19, 2019 through June 21, 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 because you had a seizure due to a procedure performed by the provider. 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 show that you received inpatient hospital care from June 19, 2019 through June 21, 2019. You were asked to pay a $285 copayment per day from June 19, 2019, through June 20, 2019, days 1-2 of your inpatient hospital care. You were discharged on June 21, 2019 and there was no copayment charge for the day of discharge. 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 provided from June 19, 2019 through June 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhome delivered meals (S5170) provided on July 26, 2019.You asked the Plan to pay forhome delivered meals. You say that these meals should be covered.The Plan denied your request. The Plan sayshome delivered meals are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that home delivered meals may be offered as a supplemental benefit, but are not covered under Medicare.We looked at the file and Medicare rules. The Plan does not offer a supplemental benefit for home delivered meals. Based on this information, we decided that Medicare rules for coverage of home delivered meals have not been met.Therefore, we decided that the Plan does not have to pay forhome delivered meals (S5170) provided on July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection services (Q9993) provided on October 19, 2018.You asked the Plan to waive the coinsurance for the injection services (Q9993). You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received an injection on the date of service at issue in this appeal. The plan states the correct coinsurance has applied per your contract with the plan.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. We looked that the file, the Plan contract and Medicare rules. The file shows you received an injection on October 19, 2018. You have been asked to pay a 20% coinsurance for the injection services (Q9993), totaling $120.83. The injection services (Q9993) fall 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 the injection services (Q9993) provided on October 19, 2018.Your complaint about how long the Plan takes to process claims 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on March 29, 2019.You asked the Plan to pay forthe 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.Therequested 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 physician services provided on March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperthermia treatment (77605 and 77280) provided on November 19, 2018 by out of network provider.You asked the Plan to pay for hyperthermia treatment. You say that these services should be considered authorized because of the letter you received from the enrollee's PCP.The Plan denied your request. The Plan says there was no valid referral or authorization 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. 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. The letter you received about medical clearance does not constitute a valid referral.Therefore, we decided that the Plan does not have to pay for hyperthermia treatment (77605 and 77280) provided on November 19, 2018 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) services provided from January 9, 2019 through February 11, 2019.You asked the Plan to waive the copayment forthe SNF services. You say that you were not told that you had gone over the last fully covered day of SNF care.The Plan denied your request. The Plan says that the copayment is your responsibility.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 $25 copayment each day for days 21 -100 for Medicare-covered stays at a SNF. You have been asked to pay $75 copayment for the SNF services. The file indicates you were in a SNF for 34 days and are responsible for a $25copayment for 14 days. This means that you have been asked to pay less than the applicable copayment 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 skilled nursing facility (SNF) services provided from January 9, 2019 through February 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and comprehensive oral evaluation provided on August2, 2019.You asked the Plan to pay forthe prophylaxis and comprehensive oral evaluation. You say that you were not informed that this provider was not in-network with your plan at the time of your appointment. You also say that after you received the denial of payment, you questioned the office staff and they told you then that this provider was not a contracted provider with your plan.The Plan denied your request. The Plan says these services were rendered by an out-of-network provider. The Plan also says that you did not make any calls to the customer service department to confirm the network status of this provider.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe prophylaxis and comprehensive oral evaluation provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services billed under code 99232.You asked the Plan to pay for this service. The Plan denied your request. The Plan says CPT code 99232 denied on claim for date of service July 16, 2019 because the same CPT code,99232, was also billed on claim number 820192000403947 for the same date of service. Both claims were processed under the same specialty (08-Internal Medicine) and same tax identification number. The Plan reviewed the provider NPI'sthat were billed on the claims and also they were billed with different NPI numbers the taxonomy was the same on both claims showing Internal Medicine as the specialty. Providers of the same group and specialty are considered the same provider. As the denied claim and referring claim are processed under the same spec-code/TIN, this edit sees them as the "same provider" which caused the Z09 edits to invoke correctly.The CMS MUE table is our guide for units/frequency if a code has a published value for Medicare Advantage plans. For CPT 99232 the CMS MUE value is "1", therefore it would not be expected that this code was submitted more than once on a single date of service. After the maximum number of times is reached, additional submissions of the procedure are not paid by Medicare. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, code 99232 cannot be paid as billed due to previous claim for the same date of service submitted by a provider within the same group. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay for physician services billed a second time under code 99232
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (J1642, J2001) provided to you on January 16, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not separately billable.The Plan must follow Medicare rules. Medicare rules say that that if performed to facilitate the chemotherapy infusion or injection, the above services are not separately billable.We looked at the file and Medicare rules. Both the heparin and saline were used as part of the flush and are included in the payment for the chemotherapy administration. These services are not separately payable. 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 (J1642, J2001) provided to you on January 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordemonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device provided on April 17, 2018.You asked the Plan to pay fordemonstration and/or evaluation of patient utilization. You say that the Plan should pay this claim.The Plan denied your request. The Plan says medical records do not document that any education or demonstration was provided.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 94664 is demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device.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 demonstration and/or evaluation of patient utilization. Our physician reviewer found Current Procedural Terminology (CPT) code 94664 -Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device billed to the health plandoes not meet criteriafor billing or reimbursement consideration.  The layman description for CPT code 94664 states that "a demonstration is done for the patient on how to use an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing device (IPPB) and/or the patient's utilization is evaluated."  This description is not notedin themedical records provided.  The medical record only states the "Pt is compliant with CPAP and has download available for review, instructed to bring chip with each visit."  This is not enough information to corroborate a demonstration, an evaluation, or that any education was provided.  Medicare rules state, 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 documentationand confirm that Medicare coverage criteria have been met. Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid up coding. A HCPCS/CPT code may be reported only of all services described by that code have been performed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of demonstration and/or evaluation of patient utilization have not been met.Therefore, we decided that the Plan does not have to pay fordemonstration and/or evaluation of patient utilization of an aerosol generator,nebulizer, metered dose inhaler or IPPB device, CPT 94664,provided on April 17, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from May 5, 2018 to May 31, 2018.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care and the provider rendered services knowing priorauthorization was 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, outof 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 home health services provided to the enrollee from May 5, 2018 to May 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlodging/hotel services received from July 18, 2019 to August 1, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis was not rendered by a medical provider.The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.The Red Roof Inn is not a Medicare-eligible provider. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlodging/hotel services received from July 18, 2019 to August 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayment for the outpatient surgical services you received on July 15, 2019.You asked the Plan to waivethe copayment. ThePlan denied your request. The Plan says you are responsible for the cost share.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 services not provided in an ambulatory surgical center. Review of the file shows that you received outpatient surgical services on July 15, 2019. Per your contract with the Plan,there is a $300 copayment for outpatient surgery services. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was insert $65.49. Given that the allowed amount was less than the $300 copayment, you have been asked to pay $65.49for these services.Therefore, we decided that the Plan does not have to waivethe copayment for the outpatient surgical services you received on July 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit you had with an out-of-network provider on March 6, 2019.You asked the Plan to waive the visit. The Plan denied your request. The Plan says you are responsible for the cost share.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% coinsurance for each office visit. Review of the file shows that you had an office visit on March 6, 2019. The visit was allowed at $236.79. You have been asked to pay a 40% coinsurance for the visit, totaling $94.71 ($236.79 x 40% = $94.71). The visit falls within the physician 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 coinsurance for the office visit you had with an out-of-network provider on March 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided in an urgent care center provided by the out of network provider.
You asked the Plan to pay for the services provided in an urgent care center. You say that the services should be paid as they were urgently needed. The Plan denied your request. The Plan says the Plan agrees that the services were urgent, however this code is not payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that procedure codes with a status code of "I", indicate that such codes are not valid for Medicare purposes and are not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided in an urgent care center provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on September 13, 2019. You asked the Plan to pay for the compression stockings. You say that your doctor has identified issues with the veins in your legs and told you to wear them before you receive surgery. The Plan denied your request. The Plan says gradient compression stockings A6533 are non-covered for venous insufficiency or leg swelling. The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6533 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The rules say that compression stockings described by code A6533 are non-covered because they do not meet the statutory definition of a surgical dressing.  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on September 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 29, 2019 to April 17, 2019 by out of network provider.You asked the Plan to pay forhome health services. You say that you took over a lot of house calls. You say that this was unexpected and taking over the services is medically necessary.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 fromnetwork 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 February 29, 2019 to April 17, 2019 by an out of network provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 4, 2019 by out of network provider, "the provider".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 emergent and the same services could be provided by in-network providers.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 4, 2019 by out of network provider, "the provider".