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

We decided that the Plan does not have to pay for the home infusion therapy rendered from August 5, 2019 to August 12, 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.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from August 5, 2019 to August 12, 2019.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pulp vitality tests (D0460) provided on August 30, 2019.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the pulp test is denied due to as an inclusive procedure.
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. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. The dental policy does not provide the benefit for the pulp test on the same day as the major service. Therefore, we decided that the Plan does not have to pay for pulp vitality tests (D0460) provided on August 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital stays from April 8, 2019 to April 27, 2019.
You asked the Plan to waive the copayment for inpatient hospital stays. 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 $325 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from April 8, 2019 to April 21, 2019. Therefore, you are responsible to pay a $325 copayment for days 1-5. $325 (copayment) x 5 (inpatient days) = $1,625.00. You had an inpatient hospital stay from April 24, 2019 to April 27, 2019. Therefore, you are responsible to pay a $325 copayment for days 1-3. $325 (copayment) x 3 (inpatient days) = $975.00. The total amount you owe is: $2,600.00. You have been asked to pay the total copayment amount of $2,600.00 for inpatient hospital stays. Inpatient hospital stays fall 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 inpatient hospital stays from April 8, 2019 to April 27, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided.
You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration as the member has been receiving care from this provider and changing providers would be highly risky. The Plan denied your request. The Plan says services from Medicare opt-out providers are not covered under the enrollee's plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the doctor. This provider has opted out of the Medicare program. The file shows that the doctor entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation care and a CT scan provided from July 16, 2019 through July 17, 2019.
You asked the Plan to waive the copayment for the services. You say that you had a CT scan biopsy due to puncture the right lung and were placed in observation waiting for the pulmonary edema to close. You state you should have been placed in a recovery process rather than allowing you to wait in the next step room. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received observation care from July 16, 2019 through July 17, 2019. The Medicare-allowed amount for the observation care is less than the set $325 copayment; therefore, you have been asked to pay the lesser amount of $316.09 for the observation care. You are asked to pay a $300 copayment for the CT scan. 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 observation care and a CT scan provided from July 16, 2019 through July 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the insertion of a catheter into the coronary arteries (93458) provided on September 6, 2019.
You asked the Plan to reduce the copayment for the catheter insertion. You say that you would like your copayment reduced to $50. The Plan denied your request. The Plan says per the EOC; you are liable for this member cost share.
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 outpatient hospital services. You have been asked to pay a $400 copayment for the catheter insertion. The catheter placement falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the insertion of a catheter into the coronary arteries (93458) provided on September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the out of area laboratory services.
You asked the Plan to pay for the out of area laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out of area care.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The file shows that the laboratory services were not provided due to an unforeseen illness or condition. Based on this information, we decided that Medicare rules for coverage of the out of area laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the out of area laboratory services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99512 provided from July 2, 2019 to July 30, 2019.You asked the Plan to pay for CPT code 99512. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. In this case, CPT code 99512 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service.Therefore, we decided that the Plan does not have to pay forCPT code 99512 provided from July 2, 2019 to July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 37252 provided on July 30, 2019. You asked the Plan to pay for CPT code37252. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare rules say that CPT Code 37252 is a Type 1 add-on code and must be reported with a proper Primary Code. In this case, CPT Code 37252 was billed without an appropriate primary code per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for CPT code 37252 provided on July 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the endodontic therapy provided on August 15, 2019.
You asked the Plan to pay more for the endodontic therapy. You say that you went to an out-of-network provider because you would have had to drive over 100 miles to see the closest in-network endodontist. The Plan denied your request. The Plan says this claim was able to be re-processed at the in-network level of benefits. The Plan also says that you reached your $1,000 annual maximum for the year and you are responsible for the remaining balance.
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 Plan is only obligated to pay $1,000 every year. The record shows that you have met this annual maximum and are responsible for the amount over the annual maximum benefit amount. Therefore, we decided that the Plan does not have to pay more for the endodontic therapy provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the guidance for localization of target volume for delivery of radiation treatment services coded 77387 provided to the enrollee on July 26, 2019.
You asked the Plan to pay for the guidance for localization of target volume for delivery of radiation treatment 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 a covered benefit.
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 77387 is Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed. We find that CPT code 77387 is not supported in the medical record. Specifically, code 77387 has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the guidance for localization of target volume for delivery of radiation treatment services have not been met. Therefore, we decided that the Plan does not have to pay for the guidance for localization of target volume for delivery of radiation treatment services coded 77387 provided to the enrollee on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hearing test (92557 and 92567) provided on April 26, 2019.
You asked the Plan to waive the copayment for the hearing test. You say that you paid a copayment for the office visit and did not know there would be a separate copayment for the hearing test. The Plan denied your request. The Plan says this benefit has been applied correctly per the contract.
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 hearing services. You have been asked to pay a $40 copayment for the hearing test. The hearing test falls within the hearing 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 a hearing test (92557 and 92567) provided on April 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health services provided on May 13, 2019 and August 5, 2019.You asked the Plan to waive the copayments for outpatient mental health services. You say that you feel that you should only owe a $10 copayment per each visit.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 $25 copayment for outpatient mental health care. You received outpatient mental health services on May 13, 2019 and August 5, 2019. Therefore, you are responsible to pay a $25 copayment per each visit. The total amount you owe is: $25 (copayment) x 2 (visits) = $50.00. You have been asked to pay the total copayment amount of $50.00 for outpatient mental health services. Outpatient mental health services fall within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments for outpatient mental health services provided on May 13, 2019 and August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0675). You asked the Plan to pay for a pneumatic compression device. You say that you do not agree with the responsibility on this claim and that it should be reprocessed and paid.The Plan denied your request. The Plan says a PCD with the service code E0675 are never covered.The Plan follows Medicare rules. The rules state that a PCD coded by E0675 are used for peripheral artery disease and are non-covered. An E0673 is also a non-covered item due to the place of service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0675)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (73502) provided on August 30, 2019.You asked the Plan to waive the copayment for an x-ray. You say that you were told you would not be charged for this service.The Plan denied your request. The Plan says this service 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 $10 copayment for Medicare-covered X-rays. You have been asked to pay a $10 copayment for an x-ray. 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 x-ray (73502) provided on August 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 28, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest rendered to you by on July 26, 2019.
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. 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 per day for Medicare-covered diagnostic radiology services, such as CT scans.
Review of the file shows that you had a CT scan of the chest on July 26, 2019. Per your contract with the Plan, there is a $250 copayment per day for Medicare-covered diagnostic radiology services, such as CT scans. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $136.44. Given that the allowed amount was less than the $250 copayment, you have been asked to pay $136.44 for these services. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest rendered to you on July 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on June 22, 2019.
You asked the Plan to pay for the paramedic intercept services. You say that 911 was called because you were
seriously ill and home alone and you are appealing the denial. The Plan denied your request. The Plan says
paramedic intercept services are not covered in non-rural locations.
The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the
services are furnished in a rural area.
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we
decided that the Plan does not have to pay for the paramedic intercept services provided on June 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided on July 11, 2019. You asked the Plan to waive the copayment for specialist services. You say that you were told that you were covered.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 $50 copayment for physician/practitioner services/specialist office. You have been asked to pay a $50 copayment for specialist services. The services you received were covered, leaving you with your cost-sharing obligation of $50. Specialist services fall within the physician/practitioner services/specialist office 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 specialist services provided on July 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ambulance transport provided on March 14, 2019. You asked the Plan to waive the coinsurance for the ambulance transport. The Plan denied your request. The Plan says that you were charged 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 $325 copayment for Medicare-covered ambulance services. You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance 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 coinsurance for the ambulance transport provided on March 14, 2019.