Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and comprehensive
evaluation provided on July 25, 2019.
You asked the Plan to waive the cost share for the office visit and comprehensive evaluation. You say that the
claim should be reprocessed. The Plan denied your request. The Plan says the cost share 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 your deductible is
$1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered
medical services. Your contract with the Plan clearly says that you must pay 30% coinsurance for provider and
professional services at an out-of-network PCP office or specialist's office.
The office visit you asked the Plan to waive the cost share for falls within the "Physician/Practitioner services,
including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in
the contract that your $1,000 deductible applies to out-of-network office visits. This cost sharing is a
contractual obligation that had not been met at the time the office visit was received on July 25, 2019.
You have also been asked to pay $44.80, which is 30% of the allowed amount for the comprehensive
evaluation. The allowed amount is $149.32 (30% x $149.32 = $44.80). 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 share for the office visit and comprehensive evaluation provided on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 28, 2018 by out of network.
You asked the Plan to pay for a specialist office visit. You say that the doctor called and cancelled the office visit. You say that you did not have an office visit. The Plan denied your request. The Plan says no prior authorization was obtained.
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 March 28, 2018 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Comprehensive Inherited Cancer gene panel rendered to the enrollee by the Provider on May 1, 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 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 test at issue in this appeal, the Comprehensive Inherited Cancer panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Comprehensive Inherited Cancer gene panel rendered to the enrollee by the Provider on May 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye surgery provided by the Hospital on September 6, 2019.
You asked the Plan to waive the copayment for the eye surgery. You say that you have had five eye surgeries and has paid a $350 copayment per date of service and are looking for some relief on the copays. 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 $350 copayment for outpatient surgery. You have been asked to pay a $350 copayment for the eye surgery. The eye surgery 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 for the eye surgery provided by the Hospital on September 6, 2019.
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 by HNC Medical Supplies from June 5, 2019 to August 24, 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 the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by HNC Medical Supplies from June 5, 2019 to August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of a heart lesion (33120) provided by the physician, on June 24, 2019.
You asked the Plan to pay for the removal of a heart lesion. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a claim with the same modifiers, provider and CPT code was previously allowed and paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We find that CPT code 33120 is not supported in the medical record. Specifically, this is a duplicate claim. Based on this information, we decided that Medicare rules for coverage of the removal of a heart lesion have not been met. Therefore, we decided that the Plan does not have to pay for the removal of a heart lesion (33120) provided by the physician, on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided from July 26, 2019 to August 2, 2019.

You asked the Plan to pay for the services provided. You say that the plan is inconsistent with reasons to not pay. The Plan denied your request. The Plan says the procedure code is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment. 

We find that CPT code S9328 is not supported. Specifically, Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided to from July 26, 2019 to August 2, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve podiatry services with the physician.You asked the Plan to pre-approve the podiatry services with the physician. You say that the physician much closer to the enrollee's current facility of care and it would be very difficult for the enrollee to commute to the providers office.The Plan denied your request. The Plan says that podiatry services could be safely provided by the provider .Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. 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 physician is a non-contract provider. the physician's office is 1.6 miles from the enrollee's residence. We were able to confirm that the Medicare guidelines for accessibility to podiatrists in Santa Clara County is 10 miles. The records show that the physicians office is 18 miles from the enrollee's residence. Under Medicare rules, this means that the physician is not accessible to the enrollee. The Plan has not supplied the names of contract providers located within reasonable distance and travel time from the enrollee's residence who can provide podiatry services. Therefore, we decided that the Plan has to pre-approvepodiatry services with the physician
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemo denervation procedures or the botox injection provided on February 7, 2019 and August 1, 2019.You asked the Plan to waive the cost share for the chemodenervation procedures and the botox injection. You say that the prices vary greatly for the same services.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible that applies towards in-network surgical procedures, a $150 copayment for each Medicare-covered in-network outpatient hospital facility visit after your yearly deductible is met, and 20% coinsurance for each in-network Medicare-covered Part B drug obtained in a provider's office or outpatient setting after your yearly deductible is met. The chemodenervation procedures you asked the Plan to waive the cost share falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.The botox injection you asked the Plan to waive the cost share falls within the "Medicare Part B prescription drugs" benefit category.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery provided on May 9, 2019.
You asked the Plan to waive the copayment for eye surgery. You say that the corrective surgery is not your
responsibility. You say that no copayment should have been billed. 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 $150
copayment for each visit for surgical procedures at an outpatient hospital facility.
You have been asked to pay a $150 copayment for eye surgery. Eye 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 eye surgery provided on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the drug injection you received on June 17, 2019.
You asked the Plan to waive the cost share. 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 20% coinsurance for Medicare Part B prescription drugs and a $25 copayment for provider and professional services in a specialist's office. Review of the file shows that you were provided a Part B drug injection on June 17, 2019. The drug was allowed at $1,121.40. You have been asked to pay a 20% coinsurance for the injection, totaling $224.28. The injection falls within the Medicare Part B prescription drugs benefit category. You have also been asked to pay a $25 copayment for the drug administration. The administration falls within the outpatient diagnostic tests and therapeutic services/supplies benefit category. The total you have been asked to pay is $249.28. 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 drug injection you received on June 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora home blood glucose monitor (E0607), blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution / chips (A4256), and spring-powered device for lancet (A4258) provided from June 21, 2019 to September 9, 2019.You asked the Plan to pay for the home blood glucose monitor, blood glucose test or reagent strips, lancets, calibrator solution / chips, and spring-powered device for lancet. You say that the items were provided and payment should be rendered.The Plan denied your request. The Plan says the documentation provided did not include a valid proof of delivery. Therefore, coverage criteria has not been met.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 valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket is missing a valid signature.Therefore, we decided that the Plan does not have to pay fora home blood glucose monitor (E0607), blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution / chips (A4256), and spring-powered device for lancet (A4258) provided from June 21, 2019 to September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 19, 2019 by out of network provider.You asked the Plan to pay for outpatient lab work. You say that you would like this claim to be reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained prior to the services in question. The Plan says that the referring provider is also out-of-network. The Plan says that the primary care physician did not referring the enrollee.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 August 19, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglass frames provided on June 24, 2019.
You asked the Plan to reimburse you for the eyeglass frames. The Plan denied your request. The Plan says
vision services must be received from in-network providers to be covered.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the
Plan. The Plan did not pre-approve the eyeglass frames. We found no exception that would require the Plan to
pay for the eyeglass frames. Therefore, we decided that the Plan does not have to reimburse you for eyeglass
frames provided on June 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 20, 2019 to November 8, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 20, 2019 to November 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Synvisc injection provided on September 3, 2019.You asked the Plan to waive the coinsurance for the Synvisc injection. You say that your previous drug costs less. You say that you are requesting reimbursement of the difference.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $511.55, which is 20% of the allowed amount for the Synvisc injection. The allowed amount is $2,557.77 (20% x $2,557.77 = $511.55). The Synvisc injection falls within the "Medicare Part B Prescription Drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Synvisc injection provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on July 10,2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 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 nurse practitioner services provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided on January 10, 2019.
You asked the Plan to pay for hospital discharge day management. You say that this should be covered. The Plan denied your request. The Plan says the documentation did not support that a time of 31 minutes or more was spent on this service.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not contain documentation that shows a time of 31 minutes or more was spent on this service. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) provided on January 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from March 1, 2019 to March 18, 2019.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physical therapy services provided from March 1, 2019 to March 18, 2019.