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

We decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) (95955) provided during lumbar fusion surgery on July 23, 2019.
You asked the Plan to pay for the intraoperative EEG testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are experimental and investigational.
The Plan follows Medicare rules. Medicare pays for items or services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The determination of medical necessity must be tailored to the individual patient and their unique clinical scenario.
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 the intraoperative EEG testing. Our reviewer says that the services provided do not meet criteria for coverage. Our physician reviewer found the EEG during lumbar fusion surgery is not medically necessary. The intraoperative EEG is accepted for monitoring cerebral function during carotid artery surgery or during intracranial vascular surgery. The literature indicates intraoperative EEG is investigational for all other indications because it has not been proven to be clinically valuable. The intraoperative EEG would exceed the patient's medical needs and would not be furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. 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 intraoperative EEG testing have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) (95955) provided during lumbar fusion surgery on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services (99490) provided on February 28, 2019 by out of network provider.You asked the Plan to pay for the chronic care management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollees EOC.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 requestedprovider 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 chronic care management services (99490) provided on February 28, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdomen x-ray (74018-26-77) provided on July 30, 2019.
You asked the Plan to pay for the abdomen x-ray. You say that the service was provided and payment should be rendered. The Plan denied your request. The Plan says the billed code is a duplicate claim line. Based on Medicare billing criteria, duplicate claims are not eligible for payment.
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 74018-26-77 is an abdomen x-ray. We find that CPT code 74018-26-77 is not supported in the medical record. Specifically, each claim was billed as 74018-26-77 which is duplicate billing. Code 74018-26-77 was already paid by the plan. Based on this information, we decided that Medicare rules for coverage of the abdomen x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an abdomen x-ray (74018-26-77) provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 5, 2019 by the out of network provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The rendering provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 5, 2019 by san out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided by the physician from March 10, 2017 to November 1, 2017.
You asked the Plan to pay for the acupuncture services. You say that you would like the plan to reimburse you for these services. The Plan denied your request. The Plan says the filing limit has expired.
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 acupuncture services was not filed until November 14, 2018. 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 Plan does not have to pay for the acupuncture services provided by the physician from March 10, 2017 to November 1, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the walker provided on August 26, 2019.
You asked the Plan to provide additional payment for the walker. You say that you expected additional reimbursement for the walker. The Plan denied your request. The Plan says that you were reimbursed 80% of the allowed 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 20% coinsurance for Durable medical equipment (DME) and related supplies. You have asked the plan to pay more than 80% of the allowed amount for the walker. The walker falls within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan and no further payment is due from 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 provide additional payment for the walker provided on August 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by this practice.
You asked the Plan to waive the copayment for an ambulance trip. You say that you disagree with the charges and feel that you could have driven yourself. 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for an ambulance trip. An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by the physician on September 11, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you disagree with the charges. 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 $35 copayment for each specialist visit. The medical records show that you received services beyond an annual wellness visit on September 11, 2019. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's 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 an office visit provided by the physician on September 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 28, 2019 by out of network provider, "the provider".You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The provider is only in-network for routine vision services. 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 August 28, 2019 by out of network provider, "the provider".
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was not emergent and 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. You are 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 services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for aspiration and/or injection of large joint or joint capsule (20610) provided on August 5, 2019.You asked the Plan to waive the copayment for aspiration and/or injection of large joint or joint capsule. You say that you did not have surgery. You say this was a shot done for prevention so you would not have to have a shoulder replacement.The Plan denied your request. The Plan says outpatient surgery services have a $250 copayment. The Plan also says that anytime the skin is pierced it is considered surgery.The rules saya 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 $250 copayment for outpatient surgery services. You have been asked to pay a $236.34copayment for aspiration and/or injection of large joint or joint capsule. This service falls within the outpatient surgery services benefit category. The allowable amount for this service is $236.34 which is less than the normal amount of $250. The record shows that when the skin is pierced it is considered surgery. 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 aspiration and/or  injection of large joint or joint capsule (20610) provided on August 5, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for PT provided from June 3, 2019 to June 26, 2019.You asked the Plan to waive the copayments for PT. You say that you feel that you should only owe one copayment, not 8.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 $40 copayment for PT services. You received PT from June 3, 2019 to June 26, 2019 for a total of 8 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 8 (PT visits) = $320.00.You have been asked to pay the total copayment of $320.00 for PT. PT falls within the outpatient rehabilitation 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 copayments for PT provided from June 3, 2019 to June 26, 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 August 19, 2019 through August 26, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that he presented with the same problems during his first stay. You say that you should not be billed for another five days. 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). The Plan contract clearly says that enrollees must pay $275 each day for days 1 to 5 for each Medicare-covered stay in a network hospital. The enrollee has been asked to pay a $1,375 copayment for the inpatient stay. ($275/day x 5 days = $1,375). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that this was a separate admission. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 19, 2019 through August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to you on December 26, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says procedure code 95999 is not supported.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that train of four testing was performed. Payment for this procedure is included in the payment of the already-approved neuromonitoring. 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 forthe services rendered to you on December 26, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the $20 copayment charged outpatient lab services provided on August 2, 2019.You asked the Plan to waive this copayment. You say that you have this test every year and are not normally charged a copayment.The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and the plan contract agreement for this type of service.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 copayment for outpatient lab services. 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 waivethe $20 copayment charged outpatient lab services provided on August 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ECG provided on July 26, 2019.You asked the Plan to waive the copayment forthe ECG. You say that your husband had this done during an annual and did not have a copayment. You say that the EKG should be covered as part of the physical.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 $20 per day for Medicare-covered tests. You have been asked to pay $19.08, which is less than the standard $20 copayment for the ECG. The ECG falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 ECG provided on July 26, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Tyvaso refill kit provided from
October 29, 2018 to December 14, 2018.
You asked the Plan to waive the coinsurance for the Tyvaso refill kit. You say that you should not have to pay
for this. The Plan denied your request. The Plan says that the claim processed 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 Medicare Part B prescription drugs (PA).
You have been asked to pay 20% coinsurance for the Tyvaso refill kit. The Tyvaso refill kit falls within the
Medicare Part B prescription drugs (PA) 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 Tyvaso refill kit provided from October 29, 2018 to December 14, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that the Plan should cover the services according to their policy and previous decisions.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 22, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on July 22, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you cannot afford the charges. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on July 22, 2019. The allowed mount is $5,456.80 and 20% of that is $1,091.36. You have been asked to pay the total coinsurance amount of $1,091.36 for a Medicare Part B drug injection. A Medicare Part B drug 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 a Medicare Part B drug injection provided on July 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Continuous Positive Airway Pressure (CPAP) device and humidifier, and supplies provided from December 7, 2018 to February 7, 2019.
You asked the Plan to pay for the CPAP device and humidifier, and supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee was not compliant with the CPAP usage.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP device and humidifier, and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Continuous Positive Airway Pressure (CPAP) device and humidifier, and supplies provided from December 7, 2018 to February 7, 2019.