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

We decided that the Plan does not have to waive the copayment forthe office visit provided on August 15, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you were advised you would not be charged because you did not see the doctor. You say that you only visited with the doctor's assistant.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 youmust pay a $35 copayment per specialist visit. Physician/practitioner services, including office visits, includes services performed by a PCP, specialist, physician assistant, or nurse practitioner.You have been asked to pay a $35 copayment for the office visit. The 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 forthe office visit provided on August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 28, 2019 to January 29, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's condition warranted inpatient management. The Plan denied your request. The Plan says there were no complex issues for which inpatient admission was necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee had a history of diabetes and presented with elevated blood sugar over 600. There were no signs of secondary infection or of ketoacidosis. Treatment included intravenous fluid and insulin. Blood sugar improved after one midnight's time of care and he was discharged. The record show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Inpatient admission was not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 28, 2019 to January 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on August 12, 2019.You asked the Plan to pay for the bone replacement graft (D7953). You say that you submitted your bill for review. The Plan denied your request. The Plan says the service is not a covered 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 bone replacement graft for ridge preservation (D7953) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) for tooth # 18, and the 3/4
porcelain crown (D2783) for teeth # 24 and 25 provided from February 4, 2019 to February 20, 2019.
You asked the Plan to pay for the dental services. You say that when you enrolled in the Plan in 2018 you had
dental coverage of $1,800 per year. You say that your plan was switched automatically on January 1, 2019.
You also say that you were not notified of the change in dental insurance coverage from $1,800 per year to
$450 per quarter. The Plan denied your request. The Plan says the quarterly allowance for comprehensive
dental benefits has been exceeded.
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 and the service are listed as covered,
the quarterly allowance for comprehensive dental benefits has been exceeded. Therefore, we decided that the
Plan does not have to pay for the porcelain crown (D2740) for tooth # 18, and the 3/4 porcelain crown (D2783)
for teeth # 24 and 25 provided from February 4, 2019 to February 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital rehabilitation stay provided from July 26, 2019 to August 8, 2019.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were told the inpatient stay was covered, but did not mention a copayment. 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 $215 copayment per day, for days 1-7 for in-network Medicare-covered hospital stays. You have been asked to pay a $215 per day for days 1-7 for the inpatient rehabilitation stay. ($215 x 7 = $1,505). The inpatient rehabilitation stay falls within the "Inpatient hospital stay" 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 hospital rehabilitation stay provided from July 26, 2019 to August 8, 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 July 7, 2019 through July 10, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that you were admitted but were unable to see the urologist. You say that you should not have to pay when they could not help you.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 $350 per day for days 1-5 each time you are admitted to an acute care hospital.You have been asked to pay a $1,050 copayment for the inpatient stay. ($350/day x 3 days = $1,050). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you were an inpatient for three days. 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 July 7, 2019 through July 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physical therapy provided.
You asked the Plan to waive the deductible for physical therapy. You submitted the explanation of benefits for
review. You say that payment should be made. The Plan denied your request. The Plan says the deductible
applied correctly.
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 your deductible is $300, which applies to all items and services except those
specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will
pay its share for your covered Medicare Part A and B services. Outpatient rehabilitation is not excluded from
the deductible.
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation
services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract you're
your $300 deductible applies to outpatient rehabilitation. This cost sharing is a contractual obligation that had
not been met at the time physical therapy was received.
Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 31, 2019 by out of network provider, "the provider"..You asked the Plan to pay forphysician services. You say that you provided these services in good faith.The Plan denied your request. The Plan says no prior authorization was obtained; therefore, these services have been correctly denied for payment.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on July 31, 2019 by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 1, 2019 by the out of network provider.You asked the Plan to pay for the practitioner services. You say that the services were provided to the enrollee in good faith.The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan also says the services were not urgent or emergent in nature.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 provider in this case is not a network provider with the Plan. 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 office visit provided on August 1, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe extra fitted cover and shipping provided by "the provider", Inc. on June 26, 2019.You asked the Plan to reimburse you forthe extra fitted cover and shipping. You say that you were told you could buy these items and get reimbursed.The Plan denied your request. The Plan says the extra fitted cover and postage are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member, are not covered.We looked at the file and Medicare rules. Delivery fees are not reimbursable and the extra fitted cover is not covered by Medicare. Based on this information, we decidedthat Medicare rules for coverage of the extra fitted cover and shipping have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe extra fitted cover and shipping provided by "the provider". on June 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the specimen handling services provided on May 31, 2019 billed with code 99000.
You asked the Plan to pay for the specimen handling services. You say that this should be covered as medically necessary. The Plan denied your request. The Plan says payment was made for the lab testing but not for code 99000 which is not separately payable by Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99000 is not supported as payable. The code has a status indicator of "B" in the Physician Fee Schedule. This means that payment for this is always bundled in payment for other services rendered. Based on this information, we decided that Medicare rules for coverage of the specimen handling services have not been met. Therefore, we decided that the Plan does not have to pay for the specimen handling services provided on May 31, 2019 billed with code 99000.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies provided to the enrollee from May 16,2019 to August 4, 2019.You asked the Plan to pay for the diabetic testing supplies. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the delivery ticket is missing required information.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the delivery ticket submitted did not include the carrier's tracking number. The proof of delivery did not include an order number or details to validate the delivery ticket submitted. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided to the enrollee from May 16, 2019 to August 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 8, 2019 to May 31, 2019 by an out of network provider.
You asked the Plan to pay for skilled nursing facility services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 8, 2019 to May 31, 2019 by an out of network provider..
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 11, 2019 by the out of network provider.
You asked the Plan to pay for the laboratory testing. You say that you rely on the referring physician to obtain necessary authorizations. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent in nature.
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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. 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 drug testing provided on July 11, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran injection of phenylephrine ketorolac (C9447) provided by the provider on August 26, 2019.You asked the Plan to waive the coinsurance foran injection. You say that you paid the $300 for your outpatient surgery and do not understand why you were billed for this shot.The Plan denied your request. The Plan says Medicare Part B prescription drugs have a 20% coinsurance.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for an injection. This service falls within the Medicare Part B prescription drugs benefit category. The allowable amount of $458.56 x 20% = $91.71. 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 foraninjection of phenylephrine ketorolac (C9447) provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for root canal therapy, the crown and core buildup provided on August 6, 2019.
You asked the Plan to pay for root canal therapy, the crown and core buildup. You say that you were told you had to pay $607 for the procedure. You say that you are not going to pay the additional amount. The Plan denied your request. The Plan says dental services provided by a provider who has formally "opted out" of the Medicare program are not covered or payable by the 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, services received from a provider who has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for root canal therapy, the crown and core buildup provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forinjection services received from April 26, 2019 to May 17, 2019.You asked the Plan to waive the coinsurance forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the coinsurance was applied correctly, according to your benefits and the services rendered.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 injection services. You have been asked to pay 20% coinsurance for the services. The servicefalls within the injection services benefit category, as it was supplied by a physician in addition to the office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forinjection services received from April 26, 2019 to May 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 7, 2019 by out of network provider.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 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 Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on May 7, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided to the enrollee on June 19, 2019.You asked the Plan to pay for the home infusion/specialty drug administration 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 Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, code 99601 and 99602 have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration services coded 99601 and 99602 provided to the enrollee on June 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self administered drugs provided during an inpatient stay from June 26, 2019 to June 30, 2019.You asked the Plan to pay for self administered drugs under Medicare Part B. You say that you do not believe this bill is correct.The Plan denied your request. The Plan says claims for self administered drugs must be submitted to your Medicare Part D carrier or pharmacy carrier.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay for self administered drugs provided during an inpatient stay from June 26, 2019 to June 30, 2019