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

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on August 26, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were informed you wouldn't have a copayment if nothing was wrong. You say that nothing was wrong so you do not owe a copayment. 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 $200 for each Medicare-covered in-network outpatient hospital facility visit. You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that biopsies were taken, which is considered a surgical procedure. 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 colonoscopy with biopsy provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve partial upper denture (D5213) and partial lower denture (D5214)
to be provided by the provider.
You asked the Plan to pre-approve the upper and lower partial dentures. You say that you are appealing
because the dentist pulled out all teeth except two on the top and you only have 13 left on the bottom. The Plan
denied your request. The Plan says that the plan does not allow approval of partial dentures when more than
50% of the remaining teeth require significant restoration.
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 upper and
lower partial dentures when the services are medically necessary and reasonable.
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 pre-approve the upper and lower partial dentures.
Our reviewer says that the requested items/services are considered medically reasonable and necessary in this
case. Our physician reviewer found the two canine teeth appear to be suitable to retain an upper partial denture.
The lower abutment premolar teeth have more than 75% remaining bone support and appear to be suitable for
retaining a partial lower denture. Given the presentation of this case along with the additional documentation
indicating removal of the remaining teeth/roots there is a finding of medical necessity for the requested partial
upper and partial lower dentures.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the upper and lower partial dentures have been met. Therefore, we decided that
the Plan has to pre-approve partial upper denture (D5213) and partial lower denture (D5214) to be provided by
the provider.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 20, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on June 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on April 22, 2019.You asked the Plan to pay forthe physician services. You say that you were not aware of what type of insurance the enrollee had when you provided the 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 urgentor 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 urgentcare and pre-approved care.You are not a network provider with the Plan. The rendering 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 subsequent nursing facility care provided on April 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on August 30, 2019.You asked the Plan to waive the copayment for the duplex scan. You say that this was requested as part of your annual wellness exam. You say that this was incorrectly submitted as diagnostic instead of preventive. 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 $100 copayment for each Medicare-covered diagnostic procedures and tests at an in-network outpatient hospital facility. You have been asked to pay a $100 copayment for the duplex scan. The duplex scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, wedecided that the Plan does not have to waive the copayment forthe duplex scan provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 16, 2019 by out of network provider.You asked the Plan to pay forphysician services. You say that the doctor is not aware of the patient's insurance when he sees the patient.The Plan denied your request. The Plan says the referring provider is also out-of-network. The Plan says that no prior authorization was obtained.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 forthe medical services provided on April 16,2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on July 25, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that you paid $20 for an office visit and returned for the x-ray. You say that this constitutes a single visit and your $20 should be refunded.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 $20 per day, per provider, for Medicare-covered in-network x-ray services.You have been asked to pay a $20 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 x-ray provided on July 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from June 1, 2019 to June 30, 2019.
You asked the Plan to waive the copayment for the SNF stay. You say that you should not be billed for a private room because the facility only had one type of room. 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 $0 copayment per day, days 1-20 at an in-network skilled nursing facility and a $172 copayment per day, days 21 to 100 for an in-network skilled nursing facility. You have been asked to pay a $2,488.66 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The record shows you were billed for a semi-private room. See chart below.
Dates of Service
Service
Copayment per Day
Number of SNF Days
Member Liability
May 10, 2019 to May 31, 2019
SNF care
$0
20
$0
June 1, 2019 to June 8, 2019
SNF care
$172
8
$1,376.00
June 9, 2019 to June 30, 2019
SNF care
$172
20
$1,112.66 - This is less than the standard amount because you reached your maximum out-of-pocket amount.
Total
$2,488.66
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 SNF stay provided from June 1, 2019 to June 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 13, 2019 by out of network provider. You asked the Plan to pay forphysician services. You say that the physician is unaware of the patient's insurance when he sees the patient.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question. The Plan says that the provider is also a non-participating provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-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 forthe medical services provided on May13, 2019 by out of network provide.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100) provided on July 19, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 99100 is a bundled code with no separate payment, but you are not responsible for payment of this denied 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 find that CPT code 99100 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, 99100 is a bundled code. This means that there is no separate reimbursement for this service regardless of whether it is billed with payable codes or not. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on July 19, 2019. Please note, the Plan has stated that you are not being held financially responsible for payment of this denied service.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on August 28, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you are unhappy with the service you received.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 $45 copayment. You have been asked to pay 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 August 28, 2019.We note your complaint that you are unhappy with the service you received. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the laboratory services provided on September 9, 2019 and September 23, 2019.
You asked the Plan to waive the cost share for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request. The Plan denied your request. The Plan says you received laboratory services on the dates of service at issue in this appeal. The plan states the correct cost share has applied per your contract with the plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $300 deductible for Outpatient diagnostic tests and a $20 copayment per lab once the deductible has been met. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $300 deductible for Outpatient diagnostic tests, and a $20 copayment per lab service once the deductible has been met. This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received on September 9, 2019 to September 23, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the laboratory services provided on September 9, 2019 and September 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings (code D0274) provided on August 13, 2019.You asked the Plan to pay forthe bitewings. You say that you do not have an EOC booklet but in the Guide to Enrolling booklet it shows under Preventive dental services that 1 dental x-ray(s) is allowed every year. You also say that the bitewings were your one x-ray for 2019.The Plan denied your request. The Plan says this service is not covered by the Plan.Medicaregenerally 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, thePlan only covers intraoral, complete series of x-rays (code D0210) and panoramic x-rays (code D0330). Bitewings (code D0274) are not a covered benefit under your plan.Therefore, we decided that the Plan does not have to pay forthe bitewings (code D0274) provided on August 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on March 29, 2019.You asked the Plan to waive the copayment foran ER visit. You say that this was an urgent care facility 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 $100 copayment for emergency care. You have been asked to pay a $100 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 March 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided from August 21, 2019 to August 22, 2019.
You asked the Plan to waive the copayment for an observation stay. You say that you feel that the stay was unnecessary and possibly fraudulent. 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 $150 copayment for observation services for outpatient hospital services. The medical records show that you had an observation stay from August 21, 2019 to August 22, 2019. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for an observation stay. An observation stay 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 waive the copayment for an observation stay provided from August 21, 2019 to August 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on September 24, 2018.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 submitted records do not support the billing of codes 95908, 95885, and 95999.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 95908 is nerve conduction studies; 3-4 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.We asked our coder 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 these services. Our reviewer says that the submitted records do not support the billing of codes 95908, 95885, and 95999. Our coder reviewer found CPT codes 95908 and 95885 are not supported. The record states that pedicle screws were stimulated for spontaneous EMG testing. According to CPT rules, there is a more specific code for this procedure. Unlisted CPT code 95999 is not supported. The record does not contain evidence that a neurological or neuromuscular diagnostic procedure that is separately reportable and not included in an existing CPT code was performed. The record states that train of four testing was performed. According to CPT rules, this is included in other intraoperative neuromonitoring procedures and is not separately reportable.We lookedat this coder's review, the file, and Medicare rules. 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 forthe services rendered on September 24, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from July 24, 2019 through August 16, 2019.
You asked the Plan to pay for SNF care. You say that the services should be paid. The Plan denied your request. The Plan says the member exhausted their 100 day SNF benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from December 14, 2018 through June 10, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when he has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from July 24, 2019 through August 16, 2019.