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

We decided that the Plan does not have to pay for the annual wellness visit rendered on November 19, 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 the exam exceeds the benefit limit.
The Plan must follow Medicare rules. The rules say that Medicare covers one annual wellness exam every 12 months. We looked at the file and Medicare rules. The file shows that you previously had an annual wellness exam on November 19, 2018 for which the Plan approved and paid. The exam on November 6, 2019 was performed fewer than 12 months from your previously covered exam. Therefore, we decided that the Plan does not have to pay for the annual wellness visit rendered on November 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forair ambulance services provided August 10, 2019 to September 4, 2019.You asked the Plan to pay forthe air ambulance services. You say that the services were medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the air ambulance services. Our reviewer says that the air transportation was not medically necessary. Our physician reviewer found the enrollee was not taken form an accident scene to a hospital. The enrollee was not transferred from one medical facility to another. While the enrollee may have been need of long-term custodial care, the enrollee was not in need of an air medical transport.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forair ambulance services provided August 10, 2019 to September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment applied for the inpatient hospital care provided July 15, 2019 to July 23, 2019. You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment each day for days 1-7 for Medicare-covered hospital care. You have been asked to pay a $917.51 copayment for the inpatient hospital care provided, which is less than the applicable copayment, as you have now met your out of pocket maximum of $2,800 for the year with these services provided. 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 care provided July 15, 2019 to July 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 77080 provided on September 4, 2019.You asked the Plan to pay for CPT code 77080. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says duplicate imaging reports were submitted for review. The plan states they have already paid for a claim for the same date of service, same enrollee, exact same CPT code, and same provider, which was already processed and paid.The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.In this case, there were no medical records provided confirming that two separate DXA scans were given. The medical records provided are duplicates of one another, indicating that only one DXA scan was provided on September 4, 2019.Therefore, we decided that the Plan does not have to pay for CPT code 77080 provided on September 4, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on January 28, 2020.
You asked the Plan to waive the copayment for the duplex scan. You say that you informed the staff you could only proceed if the services were approved and covered. You say that if you had known there was individual coinsurance payments, you wouldn't have had the tests done. 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 $55 copayment for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay a $55 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the duplex scan provided on January 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgical services rendered on September 18, 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 procedure code 64595 is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that OPPS status indicators indicate whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 64595. This code has an OPPS status indicator of T and is not separately payable. 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 outpatient surgical services rendered on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visits provided from
January 9, 2020 to February 10, 2020.
You asked the Plan to waive the copayment for the specialist office visits. You say that you should not be
charged the specialist copayment when you do not see a provider on your visits. 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 an $80
copayment for a specialty care physician. For each date of service, you have been asked to pay the allowed
amount of the claim because these amounts are less than the $40 copayment for a specialty care physician.
You have been asked to pay a $21.35 copayment for the specialist office visits on January 9, 2020, January 14,
2020, January 27, 2020, February 3, 2020, and February 10, 2020. You have been asked to pay a $21.36
copayment for the specialist office visit on January 16, 2020. The specialist office visits fall within the
"Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the UV
treatments received at the specialist office visits are considered medically-necessary medical care.
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 office visits provided from January 9, 2020 to
February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Jazzy Passport power wheelchair.You asked the Plan to pre-approve a Jazzy Passport power wheelchair.You say that you require a smaller and lighter wheelchair.The Plan denied your request. The Plan says the requested chair is not on the Medicare approved list of HCPC codes.The Plan must follow Medicare rules. Medicare rules say that POV/PWC coded as K0899 will be denied as not reasonable and necessary.We looked at the file and Medicare rules. The Jazzy Passport is coded K0899. Based on this information, we decided that Medicare rules for coverage of a Jazzy Passport power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a Jazzy Passport power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen equipment (S9999, E0431, A9270) provided on October 1, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the oxygen equipment. You say that the oxygen equipment should be covered. The Plan denied your request. The Plan says the item was over $1,000 and was purchased out-of-network without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that Durable Medical Equipment over $1,000 purchase from out-of-network providers must be preapproved. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the oxygen equipment (S9999, E0431, A9270) provided on October 1, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a larger quantity of CPAP filters per year. 
 
You asked the Plan to pre-approve 24 CPAP filters per year. You say that the filters get filthy and plug the air flow within two weeks. The Plan denied your request. The Plan says the they have approved 12 per year, the filters are washable and reusable, and your doctor has not written an order for a larger quantity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  
 
We looked at the file and Medicare rules. There is no physician order for a larger quantity. Based on this information, we decided that Medicare rules for coverage of a larger quantity of CPAP filters per year have not been met. Therefore, we decided that the Plan does not have to pre-approve a larger quantity of CPAP filters per year.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the cataract surgery provided on March 4, 2020.You asked the Plan to waive the copayment for the cataract surgery. You say that you were told you would have a $125 copayment because you had surgery at an ambulatory surgical center and not a hospital. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not send a complete 2020 Evidence of Coverage. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for the cataract surgery provided on March 4, 2020.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an aminophyllin injection (J0280) provided on December 10, 2019.
You asked the Plan to pay for the injection. You say that you would like reconsideration because 3 units of the drug were used. The Plan denied your request. The Plan says the documentation submitted does not support the number of units billed.
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the injection. Our reviewer says that CPT code J0280 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation only supports 1 unit of the drug administered, therefore 3 units of J0280 cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for an aminophyllin injection (J0280) provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 16, 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 billed procedure codes are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 81225 is CYP2C19 gene analysis. The definition of code
81226 is CYP2D6 gene analysis. The definition of code 81227 is CYP2C9 gene analysis. The definition of
code 81230 is CYP3A4 gene analysis. The definition of code 81240 is F2 gene analysis. The definition of code
81241 is F5 gene analysis. The definition of code 81328 is SLCO1B1 gene analysis. The definition of code
81335 is TPMT gene analysis. The definition of code 81232 is DYPD gene analysis. The definition of code
81283 is INFL3 gene analysis. The definition of code 81408 is Level 9 molecular pathology.
We find that CPT codes 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81328, 81335, 81355,
81232, 81283 and 81408 are not supported in the medical record. Specifically, there is no lab report with
results to support the billed codes. 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 laboratory
services rendered on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve ophthalmology visit. You say that you have seen several doctors but feel
that this doctor has the ability to assist with your issue. The Plan denied your request. The Plan says the denial
of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be
treated by an in-network ophthalmologist.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided from 10:24 AM on October 24, 2019 through 6:40 PM on October 26 2019.
You asked the Plan to pay for the post stabilization inpatient care. You say that the enrollee qualified for inpatient care. The Plan denied your request. The Plan says that the enrollee's emergency medical condition stabilized.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the post stabilization inpatient care. Our reviewer says that inpatient care was not medically reasonable and necessary for the enrollee in this case. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. Our physician reviewer found that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the post stabilization inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the post stabilization inpatient care provided from 10:24 AM on October 24, 2019 through 6:40 PM on October 26 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out of network (OON) provider.You asked the Plan to pay for the breathing capacity test (94010). You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this service may be provided by a Plan participating 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-networkproviders 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 January 22, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on January 15, 2020. 
 
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you have additional insurance in effect which should reduce or eliminate your 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 $250 copayment for each Medicare-covered in-network outpatient hospital facility visit.  
 
You have been asked to pay a $250 copayment for the upper GI endoscopy. The upper GI endoscopy 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 copayment for the upper GI endoscopy provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that you have been under the care of this
physician for over 5 years due to a leaking valve and an enlarged aorta and you want to continue seeing this
physician. The Plan denied your request. The Plan says coverage for services with out-of-network providers are
allowed only when the service is medically necessary but unavailable within the network or when an
emergency. The Plan says that this is not the case there is no medical necessity for an out-of-network provider
at the present time.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the
requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on October 23, 2019 from a nonparticipating
provider.
You asked the Plan to pay for the hearing aids. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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.
Your EOC states, the plan will cover more hearing care than what Medicare covers, but you must use a doctor
in the plan's hearing network. 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 hearing aids purchased on
October 23, 2019 from a non-participating provider.