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

We decided that the Plan does not have to pay for a home visit (99350) provided on September 11, 2019. 
 
You asked the Plan to pay for the home visit. You say that you would like reconsideration because these services where medically necessary. The Plan denied your request. The Plan says the billed code does not appropriately reflect the services rendered by the provider. 
 
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 99350 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. 
 
We find that CPT code 99350 is not supported in the record. Specifically, the record does not indicate that at least two of the three following services were performed: a comprehensive interval history; a comprehensive examination and/or medical decision making of moderate to high complexity. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit (99350) provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable


 We decided that the Plan does not have to waive the coinsurance for the ostomy supplies provided on March 2, 2020. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that there has been no coinsurance for the last 7 years. You say that the cost will be difficult to pay. 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 prosthetic devices and medical supplies.  
 
You have been asked to pay a total of $37.10 for the ostomy supplies.  
 
Supply Allowed Amount Coinsurance Member Liability Skin Barrier $80.60 20% $16.12 Ostomy Deodorant $42.14 20% $8.42 Ostomy Pouch $62.80 20% $12.56 TOTAL:   $37.10 
 
The ostomy supplies fall within the "Prosthetic devices 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 the ostomy supplies provided on March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork provider on January 22, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 13, 2020 through January 15, 2020. You asked the Plan to waive the copayment for the inpatient stay. You submitted your bill for review. 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 $350 copayment per stay. You have been asked to pay a $350 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 13, 2020 through January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 21, 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered on November 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the durvalumab injection provided on December 10, 2019. You asked the Plan to waive the coinsurance for the durvalumab injection. You say that you understand owing $97.95 to reach your copayment limit but not another $902.76. 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% for each Medicare-covered Part B drug from an in-network provider. You have been asked to pay $902.76, which is less than the standard 20% coinsurance for the durvalumab injection because you met your maximum out-of-pocket. The durvalumab injection falls within the "Medicare Part B prescription drugs" benefit category. The records show that your maximum out-of-pocket was not met prior to receiving the durvalumab injection. 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 durvalumab injection provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient mental health visits provided from August 21, 2019 to March 12, 2020 
 
You asked the Plan to waive the copayments for the outpatient mental health visits. You say that you believed the visits were covered because you had not received any bills. The Plan denied your request. The Plan says the deductible charges were removed and the claims were reprocessed with the correct cost sharing amount. The Plan says the visit on March 5, 2020 was paid at 100%. 
 
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 after the deductible is met for each in-network individual or group therapy visit.  
 
You have been asked to pay a $40 copayment for each of the outpatient mental health visits. ($40 x 6 visits = $240). The outpatient mental health visits fall within the after the "Outpatient mental health 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 copayments for the outpatient mental health visits provided from August 21, 2019 to March 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from May 1, 2019 to May 2, 2019. 
 
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 
 
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 inpatient admission. 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 from May 1, 2019 to May 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish provided on March 13, 2020. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that you have not had a comprehensive examination. You also say that you do not understand if just a cleaning or x-rays were covered. The Plan denied your request. The Plan says this is not a covered service under your plan. 
 
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 topical application of fluoride varnish provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 8, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered on January 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) provided on February 24, 2020 by an in-network provider. 
 
You asked the Plan to pay for the dental services. You say that your previous provider left the practice and had no option but to choose another provider that was in-network. You state you do not know where you are to go for dental services if your provider is no longer available. The Plan denied your request. The Plan says you exhausted your benefit frequency limit. 
 
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. 
 
Review of the file show that you received a dental exam on February 24, 2020 from an in-network provider. Your EOC states that the service the exam (D0150) is covered once every three 3years and, per your claim history, payment was issued for the exam (D0150) billed for October 23, 2018 which is within the three year limitation. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation - new or established patient (D0150) provided on February 24, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on January 21, 2020. 
 
You asked the Plan to waive the copayment for wound debridement. You say that you received a 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 $225 copayment per visit for  outpatient surgery or  procedure. 
 
You have been asked to pay a $225 copayment for wound debridement. Wound debridement falls within the "Outpatient hospital 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 wound debridement provided on January 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound care provided from March 24, 2020 to April 14, 2020. You asked the Plan to reduce the copayments for the wound care. You say that you thought you would owe a $30 specialist copayment for the services. You say you were never told there would be a facility charge. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment per in-network visit. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $350 copayment for wound care. You have been asked to pay a $318.47 copayment for the wound care on each date of service. The wound care 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 reduce the copayments for the wound care provided from March 24, 2020 to April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on March 13, 2020. You asked the Plan to pay for the outpatient hospital 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 outpatient hospital services provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 17, 2020. You asked the Plan to waive the copayment for a specialist visit. You say that you do not understand why the visit was necessary prior to a 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 a visit with a specialist. The medical records show that you had a specialist visit on February 17, 2020. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for a specialist visit. A 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 a specialist visit provided on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided from December 24, 2019 to February 26, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 did not pre-approve the laboratory services. 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 laboratory services provided from December 24, 2019 to February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hemodialysis provided from January 3, 2020 through January 31, 2020.
You asked the Plan to waive the coinsurance for hemodialysis. You say that dialysis is needed three times per week. You say that the additional cost is a financial burden. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare-covered dialysis services within the service area when ordered by your PCP. The enrollee has been asked to pay $65.52, which is 20% of the allowed amount for each hemodialysis visit. The allowed amount is $327.60 (20% x $851.76 = $65.52). The total amount you owe is $851.76 ($65.52/visit x 13 visits = $851.76). Hemodialysis falls within the "Services to treat kidney disease" benefit category. 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 coinsurance for hemodialysis provided from January 3, 2020 through January 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from February 6, 2020 to March 10, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 psychotherapy services provided from February 6, 2020 to March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for UroVysion fluorescence in situ hybridization (FISH) testing
provided on January 16, 2020.
You asked the Plan to pay for FISH test. You say that this test is covered for the diagnosis code billed. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because molecular
genetic screening testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or
clear intent to order the specific lab service. Without documentation of intent to order this testing, it has not
been shown that this test was performed for covered purposes. Based on this information, we decided that
Medicare rules for coverage of FISH test have not been met. Therefore, we decided that the Plan does not have
to pay for UroVysion fluorescence in situ hybridization (FISH) testing provided on January 16, 2020.