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

We decided that the Plan does not have to waive the co-payment for the office visit received on December 21, 2020 and to pay for the handling and/or conveyance of specimen for transfer from the office to a laboratory services received on November 19, 2020 and December 21, 2020.

You asked the Plan to waive the co-payment for the office visit and to pay for the handling and/or conveyance of specimen for transfer from the office to a laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 co-payment for provider and professional services received in a specialist's office.

After looking at all of the information in this case, we found that you do not owe any money for handling and/or conveyance of specimen for transfer from the office to a laboratory services. Since you owe no money, there is no need for a coverage decision for these services.

You have been asked to pay a $50 co-payment for the office visit. The office visit falls within the physician/practitioner 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 co-payment for the office visit received on December 21, 2020 and to pay for the handling and/or conveyance of specimen for transfer from the office to a laboratory services received on November 19, 2020 and December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided November 8, 2019.

You asked the Plan to pay for the automatic external defibrillator. You say that claim denied for timely filing. Requesting reconsideration on your decision. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.

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 automatic external defibrillator was not filed until January 13, 2021. 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 automatic external defibrillator (K0606) provided November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the laboratory tests provided on November 7, 2019.

You asked the Plan to waive the co-payment for the laboratory tests. You say that the services were done the same day as the physical and the charges should be reversed. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 for Medicare-covered laboratory tests.

You have been asked to pay a $10 co-payment for the laboratory tests. The laboratory tests fall 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 co-payment for the laboratory tests provided on November 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for arthroscopy provided on October 22, 2020.

You asked the Plan to waive the co-payment for arthroscopy. You say that you were told that you would only owe a $300 co-payment and disagree with the additional $50 charge. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 co-payment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

You have been asked to pay a $350 co-payment for Arthroscopy. Arthroscopy 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 co-payment for arthroscopy provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received on January 8, 2021.

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 this service was billed incorrectly.

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 99214 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.

We find that CPT code 99214 is not supported in the medical record. Specifically, this code was billed with diagnosis codes H04.121 (Dry eye syndrome of right lacrimal gland) and H04.122 (Dry eye syndrome of left lacrimal gland). A more specific (bilateral) code is available. Therefore, it is not appropriate to bill both left and right diagnosis codes.Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.Therefore, we decided that the Plan does not have to pay forthe office visit received on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) received November 30, 2020.

You asked the Plan to pay for the unspecified adjunctive procedure. You say that your normal provider was closed due to the pandemic. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified adjunctive procedure (D9999) received November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98943) provided October 12, 2020.

You asked the Plan to pay for the chiropractic services. You say that upon verification of this enrollee's policy, you were informed that there is no visit maximum for chiropractic services along with 100% coverage.The Plan denied your request. The Plan says the benefit limit has been exceeded.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The plan offers chiropractic benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. Only 1 manipulation code is covered per date of service. The enrollee had received the maximum number of non-Medicare covered chiropractic services in 2020 and further benefit was available until January 1, 2021.Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98943) provided October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on January 19, 2021.
You asked the Plan to pay for the re-cement or re-bond of a crown. You say that this claim should be covered by your dental plan. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond of a crown provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for medical supplies. We decided that the Plan does not have to waive the coinsurance for medical supplies.

You asked the Plan to waive the copayment for medical supplies. You say that you do not agree with these charges. The Plan says that the correct copayment has been applied.

We decided that the Plan has to waive the copayment for medical supplies. The services that were provided require a 20% coinsurance, not a $45 copayment. Therefore, we decided that the Plan has to waive the copayment for medical supplies.

We also decided that the Plan does not have to waive the coinsurance for medical supplies.

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 of the allowed amount for medical supplies. The total allowed amount is $1,292.20. The total amount you are being asked to pay is $258.44 ($1,292.20 x 20% = $258.44). Therefore, we decided that the Plan does not have to waive the coinsurance for medical supplies.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 23, 2020.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says this provider is not eligible to bill Medicare. The QIC administratively overturned the Plans denial for lack of documentation to support their denial. The Plan requested a reopen and provided the required documentation.
The Plan is correct in this case. Medicare can only pay for services provided by providers who are eligible bill under Medicare payment structures. Medicare does not pay for services rendered by free standing emergency centers that are not affiliated with a hospital. The provider in question is a free-standing emergency clinic and is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for physician services provided on May 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on January 19, 2021.

You asked the Plan to waive the copayment for the specialist visit. You say that you shouldn't be responsible for an office visit copayment for a teleservice.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 $40 copayment per specialist visit.

You have been asked to pay a $40 copayment for the specialist visit. The specialist 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 the specialist visit provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on December 4, 2020.
You asked the Plan to waive the copayment for vision care. You say that the provider is showing as in-network and you should not owe a 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 $60 copayment for out-of-network vision care. The record shows that you received vision care from an out-of-network provider on December 4, 2020. Therefore, you are responsible to pay $55, which is less than the $60 copayment. You have been asked to pay $55 for vision care. Vision care 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 copayment for vision care provided on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for chiropractic services provided on January 7, 2021.
You asked the Plan to waive the deductible for chiropractic services. You say that you do not have a deductible and you would like this fixed. The Plan denied your request. The Plan says the correct deductible has been applied.
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 $198 deductible for chiropractic services. The item or service you asked the Plan to waive the deductible for falls within the benefit category chiropractic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for chiropractic services. This cost sharing is a contractual obligation that had not been met at the time chiropractic services was received on January 7, 2021. The total amount you are being asked to pay is $37.69. Therefore, we decided that the Plan does not have to waive the deductible for chiropractic services provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 9, 2020.
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 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, a cardiovascular risk assessment 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 laboratory services rendered on September 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you have not had much therapy and need more rehabilitation. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November
2, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you did not request the
services and could have had your son drive you. 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 $225
copayment for ambulance services.
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall 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 ambulance services
provided on November 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam and services provided on December 15,
2020.
You asked the Plan to pay for the services provided. You say that your provider cannot resubmit the bill. The
Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. The file shows that you received a routine eye exam and refraction
services from an out-of-network provider. The Plan rules say that they cover up to $75 for routine eye services
from an out-of-network provider. You pay any amount over $75 for the services. Therefore, we decided that
the Plan does not have to further pay for the routine eye exam and services provided on December 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day and does not require frequent self-adjustment of insulin dosage based
on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of
a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous
glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from November 2, 2020, through December 10, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were not asked for payment until the last session, and it isn't your duty to pay for physical therapy. You say that insurance should make payment. 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 $40 copayment for each Medicare-covered physical therapy and speech-language therapy visit. You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $240 ($40/visit x 6 visits = $240). Physical therapy 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 copayment for physical therapy provided from November 2, 2020, through December 10, 2020.