Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME purchased from an out-of-network provider, on July 2, 2019.
You asked the Plan to pay for the DME. 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. 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 DME purchased from an out-of-network provider, on July 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for post-cataract laser surgeries provided on July 22, 2019 and August 12, 2019.You asked the Plan to waive the copayments for eye surgeries. You say that these surgeries were needed due to film over your eyes after cataract surgery.The Plan denied your request. The Plan says the copayment amount you are being charged are correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $150 copayment for each in-network eye surgery at an ambulatory surgical center. There were 2 surgeries, resulting in a total copayment obligation of $300.You have been asked to pay $150 copayment for each eye surgery. Eye surgeries fall 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 copayments for post-cataract laser surgeries provided on July 22, 2019 and August 12, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services rendered to you on August 29, 2019.You asked the Plan to waive the copayment for these services. You say that you should only have to pay a $30 copayment.The Plan denied your request. The Plan says the copayment was 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 Medicare-covered outpatient mental health care. Review of the file shows that you received outpatient mental health services on August 29, 2019. You have been asked to pay a $40 copayment for these services. These services fall within the Medicare-covered 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 copayment forthe services rendered to you on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug injections you received on July 19, 2019.You asked the Plan to waive the coinsurance. You say that you only had a copayment the last time you received these services.The Plan denied your request. The Plan says the claim processed 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 20% coinsurance for Medicare Part B covered drugs. Review of the file shows that you received Part B drug injections on July 19, 2019. The drug injections were allowed at a total of $12,605.79. You have been asked to pay a 20% coinsurance for the injections, totaling $2,521.16 ($12,605.79 x 20% = $2,521.16). The injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waivethe coinsurance for the Part B drug injections you received on July 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on August 1, 2019 and billed under codes 15823. You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says while codes 14301 and 67912 were paid, the records provided do not support the billing of code 15823.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and when necessary the specific records that support both  the services billed and the Medicare coverage criteria. In this case, code 15823 is not supported by the medical records provided. 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 services provided to the enrollee on August 1, 2019 and billed under code 15823.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by out of network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says the services were provided from out-of- network physicians, services were not plan directed and no authorization on file.
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 July 24, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on June 6, 2019.You asked the Plan to pay for the subsequent hospital care 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 included in another code.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, we have confirmed that code 99232 for the subsequent hospital care services has a bundled relationship with code 99233 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on June 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of an erupted tooth or exposed root (D7410) for teeth # 25 and 26 provided on May 21, 2019.You asked the Plan to pay for the dental services. You say that the extractions should be covered as it was due to an accident. You also say that you did not voluntarily have 2 teeth extracted.The Plan denied your request. The Plan says only preventive dental services are covered. The Plan says that extractions are not a preventive dental service and therefore 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 extractions are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe extraction of an erupted tooth or exposed root (D7410) for teeth # 25 and 26 provided by on May 21, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by out of network provider.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent and there were in-network providers available that could provide the services at issue.
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 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on September 13, 2018.You asked the Plan to pay fortrain of four testing. You say that this should be paid.The Plan denied your request. The Plan says this service is bundled into the payment of the primary service.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 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 train of four testing. Our reviewer says that this code is not supported by the record. Our physician reviewer found unlisted CPT code 95999 is not supported for train of four testing. According to CPT rules, train of four is included in other intraoperative neuromonitoring procedures and is not reported separately.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on September 13, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rates forthe complete series of intraoral x-rays, full mouth debridement, comprehensive oral evaluation, porcelain or ceramic crown, core buildup, including any pins when required, prefabricated post and core in addition to crown, and endodontic therapy provided on July 29, 2019 and August 3, 2019, and the first intraoral periapical x-ray andperiodontal scaling and root planing provided on August 19, 2019.You asked the Plan to pay the in-network rates forthe dental services. You say that you called the Plan and confirmed that "the dentist", was in-network prior to the servicesbeing rendered.The Plan denied your request. The Plan says the complete series of intraoral x-rays, full mouth debridement, crown, core buildup, prefabricated post and core, endodontic therapy, first intraoral periapical x-ray, and scaling and planing are not covered benefits. The Plan also says that the comprehensive oral evaluation is not covered because the rendering provider is out-of-network.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. The contract also clearly states that any services received from an out-of-network dentist are not covered benefits.Therefore, we decided that the Plan does not have to pay the in-network rates forthe complete series of intraoral x-rays, full mouth debridement, comprehensive oral evaluation, porcelain or ceramic crown, core buildup, including any pins when required, prefabricated post and core in addition to crown, and endodontic therapy provided on July 29, 2019 and August 3, 2019, and the first intraoral periapicalx-ray and periodontal scaling and root planing provided on August 19, 2019.Your complaint about "the dental office" being dishonest is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99307) provided on June 10, 2019.You asked the Plan to pay for the subsequent nursing facility care. You say that you are requesting a reconsideration of the plan's denial.The Plan denied your request. The Plan says the services could have been provided in-network.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 physician 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 service 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 subsequent nursing facility care, per day(99307) provided on June 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthroplasty provided on June 13, 2019.You asked the Plan to waive the copayment for arthroplasty. You say that you are being overcharged.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received arthroplasty on June 13, 2019. Arthroplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $7,550.79 and 20% is $1,510.16. You have been asked to pay the total coinsurance amount of $1,510.16 for arthroplasty. Arthroplasty 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 arthroplasty provided on June 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on July 20, 2019 through July 21, 2019.You asked the Plan to waive the copayment for the ED visit. You say that her prior hospitalization left her without the needed medication. You say that she was admitted to get the situation under control.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency services in an emergency room.The enrollee has been asked to pay a $120 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that the Plan paid their share of the costs for the ED visit. 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 enrolleeagreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the ED visit provided on July 20, 2019 through July 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP equipment provided on June 20, 2019 by an out of network provider. 
You asked the Plan to pay for the CPAP equipment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered benefit.
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 CPAP equipment provided on June 20, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from July 6, 2019 to July 10, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because your discharged was delayed by two days. 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 $75 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from July 6, 2019 to July 10, 2019. Therefore, you are responsible to pay a $75 copayment for days 1-4 (July 6, 2019 to July 9, 2019). $75 (copayment) x 4 (inpatient days) = $300.00. You have been asked to pay the total copayment amount of $300 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from July 6, 2019 to July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chronic care management, 20 minutes, provided on June 30, 2019 by the out of network provider.You asked the Plan to pay forthe practitioner services. 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.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 facility 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 forthe chronic care management, 20 minutes, provided on June 30, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision care office visit provided April 15, 2019.You asked the Plan to waive the copayment for the vision care office visit. You say that you were told by the provider the visit would be 100% covered as part of a follow-up from the previous visit. 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 $45 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. You have been asked to pay a $45 copayment for the vision care office visit. The vision care office visit falls within the "Vision Care" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a previous 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 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 vision care office visit provided on April 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

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 August 12, 2019.
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 enrolle by an out-of-network provider on
August 12, 2019.