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

We decided that the Plan does not have to waive the copayment for laser surgery provided on August 16, 2019 and August 23, 2019.
You asked the Plan to waive the copayment for laser surgery. You say that you question if the surgery was necessary. You say that you now have a large bill with no results. 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 $450 copayment for each visit to an ambulatory surgical center for Medicare-covered services. You have been asked to pay $434.62, which is less than the standard $450 copayment for each laser surgery. The total amount you owe is $869.24 ($434.62/surgery x 2 surgeries = $869.24). Laser surgery 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 laser surgery provided on August 16, 2019 and August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 4, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that it is the facility's responsibility to obtain the necessary authorizations. You also say that the provider is affiliated with the facility. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says that a Plan provider did not refer the enrollee for the 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 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 pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on July 4, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services provided by "the provider"  on September 3, 2019.You asked the Plan to waive the copayment forthe ambulance services. You say that you are unable to drive yourself and had lost your spouse who used to drive you in cases like this. You are unable to afford this high cost and would like the plan to cover in fullThe 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 forthe ambulance services provided by "the provider" on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ExoDx Prostate Intelliscore (EPI) testing rendered on June 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that biomarkers (specifically, EPI, MiPS, and SelectMDx) are deemed investigational.The testing at issue is the ExoDx Prostate Intelliscore (EPI) test. This test is condsidered to be investigational by Medicare and is therefore not covered.Therefore, we decided that the Plan does not have to pay forthe ExoDx Prostate Intelliscore (EPI) testing rendered on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided on August 30, 2019.You asked the Plan to waive the copayment for the outpatient clinic visit. You say that you could have gone to a specialist directly. You say that you are questioning having two copayments.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 $20 copayment for all other Medicare-covered outpatient hospital services.You have been asked to pay a $20 copayment for the outpatient clinic visit. The outpatient clinic visit falls within the "Outpatient hospital services" benefit category. The records show that the copayment is for the hospital facility charges. 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 outpatient clinic visit provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941), therapeutic exercises (97110), office visit (99203), x-ray exam of the lumbar spine (72110), supplies and materials (99070), physical therapy treatment (97039), low-level laser treatment (S8948), vertebral axial decompression (S9090), and physical medicine procedure (97139) rendered by the out of network provider from May 10, 2019 to August 16, 2019.
You asked the Plan to pay for these services. You say that you were advised that prior authorization was not required for chiropractic treatments. The Plan denied your request. The Plan says the services could have been provided by an in-network provider. Additionally, the only covered chiropractic service is manual manipulation of the spine to correct subluxation.
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 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. Additionally, the only covered chiropractic service is manual manipulation of the spine to correct subluxation. 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 chiropractic manipulative treatment (98941), therapeutic exercises (97110), office visit (99203), x-ray exam of the lumbar spine (72110), supplies and materials (99070), physical therapy treatment (97039), low-level laser treatment (S8948), vertebral axial decompression (S9090), and physical medicine procedure (97139) rendered by the out of network provider from May 10, 2019 to August 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on May 11, 2018.You asked the Plan to pay for the surgical assistant services. You say that the records support that this was correctly billed.The Plan denied your request. The Plan says this claim was filed beyond the one year filing deadline.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 surgical assistant services was not filed until July 10, 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 Plandoes not have to pay for the surgical assistant services provided on May 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from May 16, 2019 to August 4, 2019.You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is no physician order, proof of delivery, or medical records.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a validphysician order and proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from May 16, 2019 to August 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis provided on January 21, 2019. You asked the Plan to pay forthe shoulder orthosis. You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no proof of delivery documentation. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the shoulder orthosis provided on January 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for external counterpulsation (ECP) (G0166) provided on July 10, 2019.
You asked the Plan to pay for external counterpulsation. You say that this service should be covered. The Plan denied your request. The Plan says that the enrollee exceeded the 35 covered treatments.
The Plan must follow Medicare rules. Medicare rules say that a full course of external counterpulsation (ECP) therapy usually consists of 35 one-hour treatments. We looked at the file and Medicare rules. The documentation submitted contains claims for 20 ECP treatments. The record does not show that the enrollee had exceeded 35 treatments on this date of service. Based on this information, we decided that Medicare rules for coverage of external counterpulsation have been met. Therefore, we decided that the Plan has to pay for external counterpulsation (ECP) (G0166) 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency ambulance services (A0428) and ground mileage (A0425) provided on August 23, 2019. You asked the Plan to pay for the ambulance services. You say that the enrollee was not covered under hospice on the date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 20, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for emergency ambulance services (A0428) and ground mileage (A0425) provided on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) replacement lithium battery (A4235) provided August 5, 2019 to October 24, 2019.You asked the Plan to pay for the blood glucose monitor supplies. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says evidence of misrepresented services The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid delivery ticket. The delivery ticket does not include the carrier's tracking number and the proof of delivery did not include an order dumber or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay forblood glucose/reagent strips (A4253) lancets (A4259) calibrator solution/chips (A4256) replacement lithium battery (A4235) provided August 5, 2019 to October 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services billed with CPT code 99291 for dates of service June 20 - June 21, 2019.
You asked the Plan to pay for the critical care services billed with CPT code 99291. You say that the medical records support the service in dispute. The Plan denied your request. The Plan says the documentation provided does not support the CPT code billed.
The Plan must follow Medicare rules. Medicare rules say that critical care is not a service that is paid on a "shift" basis or a "per day" basis. Critical care service is paid on a time-based service provided on an hourly or fraction of an hour basis. For this reason, the documentation provided by the physician must include the amount of time in hours and minutes that is spent on providing critical care service. We looked at the file and Medicare rules. In this case, there is no evidence in the medical documentation to show the total time 30-74 spent delivering critical care to the enrollee. Based on this information, we decided that Medicare rules for coverage of the critical care services billed with CPT code 99291 have not been met.
Therefore, we decided that the Plan does not have to pay for critical care services billed with CPT code 99291 for dates of service June 20 - June 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on May 9, 2019.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed on this date of service.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Namely, the requisition form submitted was signed after this date of service had already passed, and therefore is not valid for this date of service. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on May 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on July 29, 2019 by out of network (OON) provider.
You asked the Plan to pay for the OON lab testing. You say that the medical records support this service. The Plan denied your request. The Plan says this non-emergency testing was performed OON without prior authorization and was correctly denied.
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 lab testing provided on July 29, 2019 by out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 17, 2019 by an out-of-network provider. You asked the Plan to pay for the out-of-network services. You say that the enrollee's doctor followed the recommendation of guidelines to determine if there is a more effective therapy. The Plan denied your request. The Plan says they require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the lab service 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 lab services provided on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on July 30, 2019.
You asked the Plan to waive the copayment for an ECG. You say that you feel that the ECG should be included in the office visit copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for outpatient diagnostic tests. You have been asked to pay a $10 copayment for an ECG. An ECG falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ECG provided on July 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the cleaning (D1110), or the bitewing x-rays (D0272) provided on August 21, 2019.
You asked the Plan to pay for the periodic oral evaluation (D0120), the cleaning (D1110), and the bitewing x-rays (D0272) . You say that you have seen the provider for decades and you were surprised to find out that they are not considered an 'in-network' dentist. The Plan denied your request. The Plan says the services are denied because the dentist is an out-of-network 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, out-of-network services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the cleaning (D1110), or the bitewing x-rays (D0272) provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92004) and determination of refractive state (92015) provided on July 1, 2019. You asked the Plan to pay for the eye exam and determination of refractive state. You say that the provider told you they were in-network.The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.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 foran eye exam (92004) and determination of refractive state (92015) provided on July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from June 6, 2019 through June 11, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that you were advised that  you would not have a copayment if you were admitted.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 $200 each time you are admitted to an acute care hospital.You have been asked to pay a $200 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital 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 the inpatient stay provided from June 6, 2019 through June 11, 2019.