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

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forparamedic ambulance services. You say that on the date of service the enrollee had a medical emergency that required a 911 call. You say that the ambulance responders were unable to care for the enrollee's condition and so they called for paramedic support. The paramedics provided care for the enrollee on the trip with the ambulance company to the hospitalbut did not transport the enrollee themselves. You say that the medical support services provided by the paramedics should be considered as reasonable and necessary care.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The paramedic ambulance company did not provide transport services on September 28, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive medical eye exam (92014) provided November 11, 2019.
You asked the Plan to waive the copayment for the vision services. You say that you were charged a $30 specialist copay. This was an annual diabetic eye examination and the provider you went to was an in-network provider and the $30 copay should be refunded. The Plan denied your request. The Plan says the claim was processed correctly and the correct copayment was applied per the Evidence of Coverage.
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 $30 specialist copay for Medicare covered exams to diagnose and treat diseases and conditions of the eye.
You have been asked to pay $30 for the vision services. The vision services fall within the Vision 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 comprehensive medical eye exam (92014) provided November 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on May 23, 2019.You asked the Plan to pay forthe hearing aids. You say that you would like reimbursement.The Plan denied your request. The Plan says that this is not covered out-of-network.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when obtained from a listed provider. We looked at the file and the Plan's rules. The file indicates you did not get the hearing aids from a listed provider.Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network neurologist.You asked the Plan to pre-approvethese services. You say that you would like to continue with this provider.The Plan denied your request. The Plan says the services are available from network providers.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network neurologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered to enrollee on July 3, 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 01967 and the diagnosis code are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code.In this case, the CPT Code Manual definition of code 01967 is neuraxial labor analgesia/anesthesia for planned vaginal delivery.We find that CPT code 01967 is not supported in the medical record. Specifically, the code is for a vaginal delivery and the enrollee is male. The definition of diagnosis code of O80 is encounter for full-term uncomplicated delivery. Given that the enrollee is male, these procedure and diagnosis codes are not supported. 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 anesthesia services rendered to enrollee on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the System purchased on December 9, 2019.You asked the Plan to reimburse you forthe portable oxygen concentrator. You say that you could have rented a portable oxygen concentrator for the same cost as buying it so you decided to buy one.The Plan denied your request. The Plan says you did not request 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 reimburse you for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Medicare rules say that only rented oxygen equipment is eligible for coverage. 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 at issue in this appeal. The Plan did not pre-approve the itemsat issue. Purchased oxygen equipment is statutorily non-covered by Medicare. We found no exception that would require the Plan to reimburse you for these items.Therefore, we decided that the Plan does not have to reimburse you forthe System purchased  on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from May 2, 2019 to May 17, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you met the MOOP amount of $6,700 and 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 the MOOP amount for 2019 is $6,700. Your contract with the Plan also clearly says that you must pay a $300 copayment for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from May 2, 2019 to May 17, 2019. The record shows that you had only paid $5,510.48 toward the $6,700 MOOP. Therefore, you are responsible to pay $300, which is less than the total copayment amount. You have been asked to pay $300 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay from May 2, 2019 to May 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on August 8, 2019.
You asked the Plan to pay for the physical therapy 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 physical therapy services provided on August 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from November 6, 2019 to November 9, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that the admittance was 2 days short of the minimum stay requirement. You say had you had known; you would have stayed the extra day. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for each day for days 1 to 5 for Medicare-covered hospital care. The enrollee has been asked to pay a $250 copayment for each day of the inpatient hospital stay. ($250 x 3 days = $750). The inpatient hospital stay falls within the "Inpatient hospital care" benefit 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 forthe inpatient hospital stay provided from November 6, 2019 to November 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on April 17, 2019.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that the copay 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 $225 copayment for each one-way Medicare-covered ambulance trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered 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 April 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the UpWalker purchased from the provider on November 15, 2019.
You asked the Plan to reimburse you for the UpWalker. You say that this walker was specified as medically necessary by your doctor and this supplier is the only place to purchase it. The Plan denied your request. The Plan says this supplier is not a Medicare certified durable medical equipment provider and you did not request prior authorization.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the UpWalker purchased from the provider on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on October 28, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you were not informed there would be a copayment. You say that you shouldn't be responsible for the bill.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 $10 copayment for in-network, Medicare-covered lab services. You have been asked to pay a $10 copayment for laboratory services. Laboratory services 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 copayment forlaboratory services provided on October 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on December 19, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these
services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on December
19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee suffered 4 strokes and is incapacitated. You say that the records provided support the need for the services in dispute. The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements for coverage of SNF care. The Plan says that the enrollee does not require daily skilled rehabilitation therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was alert with confusion. The enrollee received physical therapy, speech therapy, and occupational therapy. By the dates in question, the enrollee was alert with confusion. Our physician reviewer found that the enrollee required varying assist with activities of daily living and had ongoing cognitive deficits. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home ventilator rendered to enrollee on October 10, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code E0466 is not supported.The Plan must follow Medicare rules. Medicare rulessay 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 E0466 is home ventilator, any type, used with non-invasive interface, (e.g., mask, chestshell).We find that CPT code E0466 is not supported in the medical record. Specifically, there is no documentation of the length of need of the item. 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 home ventilator rendered to enrollee on October 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the Brain (70551) provided October 22, 2019 by provider.You asked the Plan to waive the copayment for the MRI. You say that the copayment should only be $45.The Plan denied your request. The Plan says the correct copayment was 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 $350 copayment for Outpatient Diagnostic Radiology. You have been asked to pay a $350 copayment for the MRI. The MRI falls within the Outpatient 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 have to waive the copayment for Magnetic Resonance Imaging (MRI) of the Brain (70551) provided October 22, 2019 by provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says this is a Part D drug, and the enrollee has no pharmacy 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 Retacrit for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroffice or other outpatient visit for the evaluation and management of an established patient (CPT Code 99213) provided on November 20, 2019.You asked the Plan to waive the copayment forthe vision care. You say that this visit was a follow-up visit to date of service September 9, 2019.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). The Health Plan verified that you previously received your preventative routine Medicare-covered eye Exams benefit on September 9, 2019. The Health Plan applied no cost share for the eye exam on September 9, 2019.  As explained in the 2019 EOC you are only allowed one routine Medicare-covered eye exam every 12 months which was applied, therefore the $50.00 copay applied to Medicare-covered eye exams on November 20, 2019 is your responsibility. 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 foroffice or other outpatient visit for the evaluation and management of an established patient (CPT Code 99213) provided on November 20,2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 21, 2019.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that prior to signing up, you were told that an out-of-network dental provider could be used, but only the in-network benefits would be paid. You say that after the services were rendered, you were told that this dentist had opted out of Medicare coverage. The Plan denied your request. The Plan says this dentist has opted out of Medicare. The Plan also says that they are unable to make payment for services provided by a dentist that has opted out of Medicare under your 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 this provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on November 21, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 1, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on August 1, 2019.