Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient rehabilitation stay provided from May 28, 2019 through June 8, 2019.You asked the Plan to waive the copayment forthe inpatient rehabilitation stay . You say that you were transferred for continued care. You say that this should be considered one admission.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 $360 copayment per day, per admission for days 1-5 and a $0 copayment per, day per admission for days 6-90 for in-network covered hospital stays.You have been asked to pay a $1,800 copayment for the inpatient rehabilitation stay. ($360/day x first 5 days = $1,800). The inpatient rehabilitation stay falls within the "Inpatient Hospital Care" benefit category. A transfer to a new facility is considered a separate admission. 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 inpatient rehabilitation stay provided from May 28, 2019 through June 8, 2019.
Appeal type: Lab
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the physician services provided on November 25, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the 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 services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on November 25,
2019 by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on July 19, 2019.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 physical therapy services provided on July 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered to the enrollee on August 21, 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 99283 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 99283 and 99284. Code 99283 is a column II code with a modifier indicator of 1 when billed with column I code 99284. Code 99283 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered to the enrollee on August 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the physician's hospital observation services provided on January 8, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The physician's services were requested at at the Hospital and provided at this facility. The Hospital is a contract provider with the Plan. The file does not show that the plan provided notice that the physician's services would not be covered prior to the services being rendered. Under Medicare rules, this means the physician's services are considered approved by the plan. Therefore, we decided that the Plan has to pay for the physician's hospital observation services provided on
January 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the breast ultrasounds provided on
October 28, 2019.
You asked the Plan to waive the coinsurance for the breast ultrasounds. You say that you need the sonogram
done each time you have a mammogram because you have dense breasts. 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 20%
coinsurance for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a
physician's office or at a free-standing facility.
You have been asked to pay $21.79 which is 20% of the allowed amount for each of the breast ultrasounds.
The allowed amount is $108.67. ($108.67 x 20% = $21.79). ($21.79 + $21.79 = $43.58). The breast
ultrasounds fall 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 coinsurance for the breast ultrasounds provided on October 28, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from August 29, 2018 to
December 31, 2018.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says nonemergent,
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 psychotherapy services provided from August 29, 2018 to
December 31, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to enrollee on October 1, 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 claim was not billed correctly.The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line on which the first four positions of the HIPPS code match the code submitted on the RAP.We looked at the file and Medicare rules. The claim was not billed with a required HIPPS code. 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 home health services rendered to enrollee on October 1, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided October 2, 2019
to October 4, 2019.
You asked the Plan to pay for the SNF services. You say that you are a valid provider and have been since
1994. The Plan denied your request. The Plan says provider ineligible. The plan cannot pay a provider who is
not eligible to participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for
services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for
the skilled nursing facility services provided October 2, 2019 to October 4, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for CPT code 70544 provided on November 16, 2019.
You asked the Plan to pay for CPT code 70544. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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. Specifically, the case file does not contain evidence that CPT code 70544 cannot
be paid as it was billed, according to Medicare rules. The file does not contain a copy of a claim that contains
both CPT codes 70551 and 70544 billed together on the same claim. It cannot be verified that payment for CPT
code 70544 is bundled with another procedure that was billed on the same date of service. Therefore, we
decided that the Plan has to pay for CPT code 70544 provided on November 16, 2019.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for BLS routine disposable supplies (A0382) provided May 14,
2019.
You asked the Plan to pay for BLS routine disposable supplies. You say that the records should support the
necessity of the service in dispute. The Plan denied your request. The Plan says this service is included in the
global fee for transportation and are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code BLS
routine disposable supplies has a bundled relationship with code A0428 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 BLS routine disposable supplies (A0382)
provided May 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 14, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that if you were given an option you would have denied the transport The Plan denied your request. The Plan says that you received the applicable procedure and as such the copayment is due.
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 $200 copayment for each ambulance trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the ambulance trip 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 ambulance transport provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473).
You asked the Plan to pre-approve removal of torus mandibularis. You say that the enrollee was pre-approved for a complete upper denture and lower partial denture but she has prominent mandibular tori. The Plan denied your request. The Plan says the requested service is not listed as a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided an in-network provider on October 8, 2019 to October 10, 2019.
You asked the Plan to waive the copayment for specialist services. You say that you saw a nurse practitioner. You say that this is not a specialist. 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 $40 copayment for physician/practitioner services/in-network/provider and professional services/specialist's office. You have been asked to pay a $40 copayment for specialist services. A nurse practitioner is considered a specialist; therefore, the correct copayment has been applied. The total amount you are being asked to pay is $80 ($40 + $40 = $80). Specialist services fall within the physician/practitioner services/in-network/provider and professional services/specialist's 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 by an in-network provider on October 8, 2019 to October 10, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after April 2, 2020.
You asked the Plan to pre-approve SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says that the requested continuation of SNF care does not meet criteria.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before April 2, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after April 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.
You asked the Plan to pre-approve Ensure. You say that you need this because you have lost weight. The Plan denied your request. The Plan says that Medicare does not pay for nutritional supplements.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan does not have to pre-approve Ensure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 4, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because there is no evidence of an established relationship between the enrollee and the ordering physician to verify the billed service.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific testing billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you take a lot of different medications and water pills. You say that you have incontinence issues as well as dehydration and do not have control. You stated that you are tired in the mornings because you are up all night going to the restroom and cannot stay away from your home for more than an hour because you need to go home to change your pads.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies maybe appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Outpatient Therapies
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 infusion services. You say that you are the closest facility where the enrollee can receive treatment, and this should be covered at the in-network benefit level to reduce financial hardship for the enrollee. The Plan denied your request. The Plan says the denial of authorization for in-network coverage of these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider. The Plan also says that the enrollee may choose to receive services from this provider at the out-of-network benefit level.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says enrollees may choose to receive most covered services from out-of-network providers using the Plan's Point-of-Service (POS) option. 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 at the in-network benefit level. The enrollee may choose to receive care from this provider using the Plan's Point-of-Service (POS) option. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs the requested incontinence supplies. You asked the Plan to reconsider their denial. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxymorphone tablets.
You asked the Plan to pre-approve Oxymorphone tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Oxymorphone tablets are not covered by the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxymorphone tablets.
Benefits for Oxymorphone tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.