Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on November 13, 2019.You asked the Plan to waive the copayment for these services. You say that you would like the plan to reconsider the amount due.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 $400 copayment for in-network Medicare-covered outpatient hospital surgery services. Review of the file shows that you received outpatient hospital services on November 13, 2019. You have been asked to pay a $400 copayment for these services. These services fall within the in-network Medicare-covered outpatient hospital surgery 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 the outpatient hospital services rendered on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to you by a chiropractor from August 14, 2019 to December 26, 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 services are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The provider submitted a claim for procedure codes 97014 (electrical stimulation) and 98943 (extraspinal manipulation). Therefore, we decided that the Plan does not have to pay for the services rendered to you by a chiropractor from August 14, 2019 to December 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on June 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 you by an out-of-network provider on June 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided from October 21, 2019 to October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the skilled nursing services. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization, therefore coverage criteria has not been met.
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 skilled nursing services provided from October 21, 2019 to October 22, 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 Power Scooter (K0806).
You asked the Plan to pre-approve the power scooter. You say that the scooter is medically necessary. The Plan denied your request. The Plan says the scooter is intended for use outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a Power Scooter (K0806).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CT scan (CPT 72125) provided on November 19, 2019.You asked the Plan to pay forthe CT scan. The Plan denied your request. The Plan says this is a duplicate service.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The records show that the services in question have been billed on a claim shown to be a duplicate of one previously processed and paid by the plan. Duplicate claims are not payable. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met.Therefore, we decided that the Plan does not have to pay forthe CT scan (CPT 72125) provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunoassay rendered on October 8, 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 83516 was not billed correctly.
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that procedure code 83516 was not billed with the required QW modifier. Therefore, we decided that the Plan does not have to pay for the immunoassay rendered on October 8, 2019.
Appeal type: Lab
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 July 3, 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 enrollee by an out-of-network provider on July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 24, 2019 by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 foundno 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 October 24, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 5, 2019. You asked the Plan to waive the copayment for these services. You say that you do not understand the rise in cost. 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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or outpatient hospital facility. Review of the file shows that you received chemodenervation services on December 5, 2019 at an outpatient hospital facility. These services are classified as surgical services. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered outpatient surgery in an ambulatory surgical center or outpatient hospital facility 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 outpatient surgical services rendered on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on August 12, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the request is denied as there was no prior authorization, and the provider had time to verify eligibility.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 office visit services provided to the enrollee on August 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray rendered on June 4, 2019.You asked the Plan to waive the copayment forthese services. You say that you were not aware that there would be a 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 $15 copayment for x-rays. Review of the file shows that you received an x-ray of the neck spine on June 4, 2019. You have been asked to pay a $15 copayment for these services. These servicesfall within the x-rays 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 x-ray rendered on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on April 10, 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 services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on April 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on October 11, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you should owe a lesser copayment because you saw a nurse practitioner.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 planmust 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 a specialist visit. You have been asked topay 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 fora specialist visit provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on February 20, 2019.You asked the Plan to pay forthe physician services.You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee enrolled in hospice from November 13, 2018 through February 21, 2019. The Plan states, per Medicare guidelines, the provider needs to bill Original Medicare for the services rendered on February 20, 2019.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe physician services provided on February 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing forthe diagnostic colonoscopy rendered on January 30, 2020.You asked the Plan to waive the cost sharing forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the deductible was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation. Your contract with the Plan says that there is $750 yearly deductible for your covered medical services and a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.The item or service you asked the Plan to waive the cost sharing for falls within the outpatient surgery benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly deductiblefor your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on January 30, 2020. The Plan applied $702.70 towards the annual deductible for these services. At this time, the yearly deductible was met. Given that the deductible charge did not cover the entire cost of the services, you have also been asked to pay a $125 copayment for these services.Therefore, we decided that the Plan does not have to waive the cost sharing forthe diagnostic colonoscopy rendered on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency transportation provided on January 28, 2020.You asked the Plan to waive the copayment for the non-emergency transportation. You say thatthecost-sharing should be waived due to all the issues experienced when arranging the transportation. The Plan denied your request. The Plan says that there is a $10 copay per one-way trips for non-emergency transportation.Medicare does not cover transportin a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers non-emergencytransportation with a $10 copayment per one-way trip. We looked at your request, the records in the case file, and the rules.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 thatenrollees must pay a $10 copayment per one-way trip for non-emergency transportation. The enrollee has been asked to pay a $10 copayment for each one-way non-emergency transportation trip. This copayment falls within the Transportationbenefit 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 copayment for the non-emergency transportation provided on January 28, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on December 9, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that this as supposed to be preventative.The Plan denied your request. The Plan says the correct copayment has been applied.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 $100 copayment for outpatient diagnostic tests/diagnostic radiology. You have been asked to pay $64.27 which is less than your copayment amount of $100 for an ultrasound. A diagnostic ultrasound was provided; therefore, the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/diagnostic radiology 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 haveto waive the copayment foran ultrasound provided on December 9, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgical services rendered to you on March 15, 2019 and March 16, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is a financial hardship. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each outpatient hospital facility visit, including physician or surgical charges.
Review of the file shows that you received outpatient surgical services on March 15, 2019 and March 16, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the outpatient hospital facility visit, including physician or surgical charges. 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 outpatient surgical services rendered to you on March 15, 2019 and March 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora computed tomography (CT) scan of the upper extremity (73200) provided on November 4, 2019 by the provider.You asked the Plan to waive the copayment for the CT scan of the upper extremity. You say that you were not aware you would be charged such a high copayment for the service.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $275 copayment for diagnostic radiology services.You have been asked to pay $109.71 (the allowed amount) for the CT scan of the upper extremity. A CT scan of the upper extremity falls within the diagnostic radiology 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 fora computed tomography (CT) scan of the upper extremity (73200) provided on November 4, 2019 by the provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ERvisit provided on November 27, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you disagree with the charges.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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 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 foran ER visit provided on November 27, 2019.