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

We decided that the Plan does not have to pay forthe initial nursing facility care, per day, for the evaluation and management of a patient (99305) provided on March 22, 2021.You asked the Plan to pay forthe evaluation and management service. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of electionuntil the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe initial nursing facility care, per day, for the evaluation and management of a patient (99305) provided on March 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.

You asked the Plan to pre-approve a sleep study. You say that the requested sleep study is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested sleep study.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a sleep study. Our reviewer says that the enrollee does not meet criteria for the requested sleep study. Our physician reviewer found the medical necessity of a sleep study (polysomnography) has not been established. The medical records do not document a sleep history, assessment of daytime sleepiness on the Epworth scale, neck circumference, or a detailed examination of the upper airway.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 30, 2018.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
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 October 30, 2018. 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 provided on October 30,
2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment (E1390) provided on August 7, 2020.
You asked the Plan to pay for the oxygen equipment. You say that the item is medically necessary. The Plan denied your request. The Plan says Medicare and the Plan will only cover the rental of oxygen devices from approved suppliers and will not cover the cost of purchasing a portable oxygen concentrator.
The Plan must follow Medicare rules. Medicare rules say that they will only pay for the rental of oxygen equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen equipment have not been met. Specifically, you purchased your oxygen equipment from an out-of-network provider. Medicare only pays for the rental of oxygen equipment. This means the item requested is a non-covered service. Therefore, we decided that the Plan does not have to pay for the oxygen equipment (E1390) provided on August 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on December 28, 2020.
You asked the Plan to waive the coinsurance for DME. You say that the device broke after a brief use and you should not be responsible for 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 DME and related supplies. You received DME on December 28, 2020. The allowed amount is $315.50 and 20% of that is $63.10. You have been asked to pay the total coinsurance amount of $63.10 for DME. DME falls within the 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. 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 DME provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran x-ray and does not have to waive the coinsurance for a Medicare Part B drug provided on February 9, 2021.You asked the Plan to waive the copayment foran x-ray and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the additional charges and feel that you should only owe a specialist 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 $20 copayment for x-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You received an x-ray on February 9, 2021. Therefore, you are responsible to pay the $20 copayment. You received a Medicare Part B drug on February 9, 2021. The allowed amount is $10.76 and 20% of that is $2.15. The total amount you owe for an x-ray and a Medicare Part B drug is: $22.15. You have been asked to pay the total amount of $22.15 for an x-ray and a Medicare Part B drug. An x-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. AMedicare Part B drug 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 copayment foran x-ray and does not have to waive the coinsurance for a Medicare Part B drug provided on February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay from February 27, 2021, to February 28, 2021.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you were discharged too soon and had to be readmitted for another procedure and feel that you should not owe a second 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 $390 copayment for days 1-5 for inpatient hospital care. The record shows that you had an inpatient hospital stay from February 27, 2021, to February 28, 2021. This is considered a new inpatient hospital admission. Therefore, you are responsible to pay the $390 copayment. You have been asked to pay a $390 copayment for an inpatient hospital stay. An inpatient hospital 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 foran inpatient hospital stay from February 27, 2021, to February 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cataract surgery (66984) provided on September 21, 2020, to September 22, 2020.
You asked the Plan to waive the coinsurance for cataract surgery. You say that the provider who completed your surgery assured that the surgery would be free. You also say that you found out after the surgery that you have a cost share and you do not have the money to pay for it. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.
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 vision care.
You have been asked to pay 20% coinsurance for cataract surgery. The allowed amount of the claim is $3,120.82, resulting in a coinsurance obligation of $624.08. The EOC confirms that 20% is the required coinsurance for this service. Cataract surgery falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for cataract surgery (66984) provided on September 21, 2020, to September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (81455) provided on December 30, 2020.
You asked the Plan to pay for targeted genomic sequence panel. You say that this testing was ordered by the enrollee's treating physician because the test results were needed to help determine the course of treatment for the enrollee. The Plan denied your request. The Plan says this test is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that test code 81455 is non-covered by Medicare for date of service December 30, 2020. We looked at the file and Medicare rules. The billed test code is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of targeted genomic sequence panel have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (81455) provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided on December 19, 2020 to February 19, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the oxygen services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek 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. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 oxygen services provided on December 19, 2020 to February 19, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 2, 2020.

You asked the Plan to pay for the laboratory 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 are not covered.

The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. 

We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe laboratory services rendered on October 1, 2020. 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 testing is 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 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 forthe laboratory services rendered on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on March 17, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you did not physically see the doctor and this was a cardiology clearance for an upcoming surgical procedure. 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 $45 copayment for specialist services. The record shows that specialist services were rendered on March 17, 2021. Therefore, you are responsible to pay the $45 copayment.
You have been asked to pay a $45 copayment for specialist services. Specialist services fall 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 specialist services provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided on November 28, 2020.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says there is no 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 an inpatient admission provided on November 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99213) provided on August 31, 2020, by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that the services were medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.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 had networkproviders available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent.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 office visit (99213) provided on August 31, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230), an unspecified preventive procedure (D1999), and screening of a patient (D0190) provided on February 9, 2021.

You asked the Plan to pay for an intraoral periapical radiographic image, an unspecified preventive procedure, and screening of a patient. You say that you do not want to change dentists and you want the Plan to pay for the services. The Plan denied your request. The Plan says the intraoral periapical radiographic image is a covered benefit, but you have exceeded the frequency limit of one every calendar year. An unspecified preventive procedure, and screening of a patient are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an intraoral periapical radiographic image, an unspecified preventive procedure, and screening of a patient have not been met. Specifically, the record shows that you had exceeded the frequency limit for the intraoral periapical radiographic image. Additionally, an unspecified preventive procedure, and screening of a patient are not covered benefits. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230), an unspecified preventive procedure (D1999), and screening of a patient (D0190) provided on February 9, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 4, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you slipped on their property and they insisted you get x-rays in the emergency room. You say that you do not think you are responsible for this bill. 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 $90 copayment for each Medicare-covered emergency room visit in-network and out-of-network.
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you received treatment in the ER. 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 ER visit provided on December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for aqueous shunt eye surgery (66185) provided on November 18, 2020, by an out of network (OON) provider.

You asked the Plan to pay for eye surgery. You say that the claim was authorized under an authorization. You also say that the services were medically necessary.The Plan denied your request. The Plan says the provider at issue is not contracted with the Plan for medical services, there was no authorization on file, no referring provider, and no misinformation given by the Plan.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent.We found no exception that would require the Plan to pay for these items/services.Please note, the authorization included in the submitted documentation was not issued by this Plan.Therefore, we decided that the Plan does not have to pay for aqueous shunt eye surgery (66185) provided on November 18, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine provided on October 24, 2020.

You asked the Plan to pay for the tetanus vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the tetanus vaccine is not covered under the enrollee's Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine provided on October 24, 2020.

Benefits for the tetanus vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.