Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit for medication monitoring providedon October 31, 2019.You asked the Plan to pay for the office visit. You say that without regular visits with this provider, you would not be able to get refills for your medication. The Plan denied your request. The Plan says you 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 servicesat 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 an office visit for medication monitoring provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 3, 2019.You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 servicesat 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 genetic testing provided on September 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular procedures (95870, 95937 and 95938) and medical equipment (A4215) provided on November 13, 2019.You asked the Plan to pay for the neuromuscular procedures and equipment. You say that you would like reconsideration because you provide technicians and equipment and bill for the technical component of nerve monitoring. The Plan denied your request. The Plan says these services describe diagnostic procedures that require a professional component modifier in place of service 22.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the neuromuscular procedures and equipment have not been met. Specifically, the record indicates that this was billed with Place of Service code 21 for inpatient hospital. Payment for these services is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for neuromuscular procedures (95870, 95937 and 95938) and medical equipment (A4215) provided on November 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on September 3, 2019.You asked the Plan to waive the copay forthe ambulance transport. You say that this was an emergency and you shouldn't have to pay for it.The Plan denied your request. The Plan says that the claim 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 $300 copay for each Medicare-covered ground transportation service. You have been asked to pay a $300 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered ground transportation service 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 copay forthe ambulance transport provided on September 3, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forobservation hospital care provided November 7 to November 9, 2019.You asked the Plan to waive the copayment forthe observation care. You say that the facility told you only the Emergency Room copayment would be applied.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 $300 copayment for Outpatient Observation Care. You have been asked to pay a $300 copayment for the observation care. The observation care falls within the Outpatient Observation 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 forobservation hospital care provided November 7 to November 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on December 13, 2019.You asked the Plan to waive the copayment foran ultrasound. You say that you shouldn't have to pay for this copayment. You say that it was part of your wellness exam.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 $25 copayment for outpatient diagnostic tests/ultrasound. You have been asked to pay a $25 copayment for an ultrasound. The services that were provided went beyond a normal wellness exam; therefore, the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/ultrasound 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 ultrasound provided on December 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on November 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 genetic testing provided on November 12, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe cataract surgery provided on August 19, 2019.You asked the Plan to waive the cost share forthe cataract surgery. You say that you do not have any member liability.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. Your contract with the Plan says that there is a $185 deductible that applies towards in-network surgery and 20% coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital or ambulatory surgical centers, including but not limited to hospital or other facility charges and physician or surgical charges. The cataract surgery you asked the Plan to waive the cost share for falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $185 deductible that applies towards in-network surgery and 20% coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital or ambulatory surgical centers, including but not limited to hospital or other facility charges and physician or surgical charges. See chart below. Date of ServiceServiceAllowed AmountDeductible/CoinsuranceMember LiabilityAugust 19, 2019Cataract surgery$650.60$185.00$20.13 -This is the amount where you met your deductible.August 19, 2019Cataract surgery$630.47($650.60 -$20.13)20%$126.09Total$146.22This cost sharing is a contractual obligation that had not been met at the time the cataract surgery was received on August 19, 2019.Therefore, we decided that the Plan does not have to waive the cost share forthe cataract surgery provided onAugust 19, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LINX Reflux Management System (43284).
You asked the Plan to pre-approve LINX Reflux Management System. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CPT code 43284 is noncovered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LINX Reflux Management System have not been met. Therefore, we decided that the Plan does not have to pre-approve LINX Reflux Management System (43284).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on August 13, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the services billed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not includea physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on August 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) following surgery for ischemic bowel and diverticular disease. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is tolerating weaning trials. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation provided on September 5, 2019.You asked the Plan to pay for the psychiatric diagnostic evaluation. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 fromout-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 a psychiatric diagnostic evaluation provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99205) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that the services are necessary. The Plan denied your request. The Plan says the services you are requesting can be provided by an in-network provider, therefore coverage criteria to be seen by an out-of-network provider has not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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-approve an office visit (99205) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 25, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented
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 November 25, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided thatthe Plan has to pay forthe acute inpatient hospital care provided from September 27, 2018 through October 2, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plandenied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from September 27, 2018 through October 2, 2018.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora needle (A4215) provided on October 1, 2019.You asked the Plan to pay fora needle. You say that this was requested by an in-network surgeon.The Plan denied your request. The Plan says this is not covered.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 rules also say codes with a status indicator of "N" are not covered.We find that CPT code A4215 is not supported in the medical record. Specifically, this code has a status indicator of "N," meaning it is non-covered. Based on this information, we decided that Medicare rules for coverage of a needle have not been met.Therefore, we decided that the Plan does not have to pay fora needle(A4215) provided on October 1, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Diagnostic Mammogram (77066) provided October 10, 2019 
You asked the Plan to waive the copayment for the mammogram. You say that the copayment should be waived because you were almost eligible for a screening mammogram. The Plan denied your request. The Plan says the correct cost share was applied. The service at issue is a Diagnostic mammogram, not a screening mammogram. The enrollee already had a screening mammogram within 366 days of the date of service.
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 $75 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $75 copayment for the mammogram. The mammogram falls within the Outpatient Diagnostic Tests 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 Diagnostic Mammogram (77066) provided October 10, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical therapy visit provided on November 8, 2019.You asked the Plan to waivethe copayment forthe physical therapy visit. You say that this copayment should be included in your outpatient surgery copayment. You say you should not be responsible for the copayment because you were not told there would be an additional cost. ThePlan 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 $40 copayment for each Medicare-covered physical therapy visit. You have been asked to pay a $40 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation services" benefit category. The record shows the physical therapy is 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 forthe physical therapy visit provided on November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses, gas permeable (V2510) purchased February
26, 2019.
You asked the Plan to pay for the contact lenses. You say that you paid $195 for the lenses and received the
$100 reimbursement which you understand is the allowance benefit limit. But you do not understand why you
are not being reimbursed the remaining $95 The Plan denied your request. The Plan says the maximum benefit
amount for eyewear has been paid.
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 any
amount above the $100 eyewear allowance.
You are requesting reimbursement of $95. The plan paid the $100 allowance for the contact lenses. You are
responsible for any amount above the eyewear coverage limit. The contact lenses 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 pay for contact lenses, gas permeable (V2510) purchased
February 26, 2019.