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

We decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on February 6, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.
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 99239 is "Hospital discharge day management; more than 30 minutes." 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found CPT 99239 is a time based code. In order to bill CPT 99239 the documentation must show that more than thirty minutes was spent providing day of discharge services to the enrollee. The provided documentation clearly states that only twenty minutes was spent providing day of discharge services to the enrollee. Therefore, the billing of CPT 99239 is not supported. Billing should default to the lesser code of CPT 99238. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services provided to the enrollee on February 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye examination and diagnostic imaging of retina providedon August 6, 2019.You asked the Plan to waive the copayment forthe eye examination and diagnostic imaging of retina. You say that you received a letter from the Plan that a diabetic eye exam would be covered in full and you believe you should not be financially liable for a copayment.The Plan denied your request. The Plan says a review of the medical records shows that a medical eye exam was performed and you are financially liable for a $20 copayment.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 copayment for vision care, medical eye exam. You have been asked to pay $20 copayment for the eye examination anddiagnostic imaging of retina. The eye examination and diagnostic imaging of retina falls within the vision care, medical eye exam 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 eye examination and diagnostic imaging of retina provided on August 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided billed with code 99231.
You asked the Plan to pay for the inpatient EM services. You say that these are separately payable visits. The Plan denied your request. The Plan says EM services were already paid for this date of service so this claim is denied correctly.
The Plan must follow Medicare rules. Medicare rules say that if a patient is seen twice in one day by two physicians, the second physician's services are not separately payable unless they are of a separate specialty. In this case, payment was made for EM services provided on June 16, 2019 by the doctor. There is no evidence that the doctor and practitioner assistant have different specialties. The services for both of these providers should have been billed together and are not separately payable. Therefore, we decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided billed with code 99231.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health services provided on August 15, 2019 and September 13, 2019.
You asked the Plan to waive the copayment for the outpatient mental health 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 outpatient mental health care on the date of service at issue in this appeal. The plan says that the correct copayment 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient mental health care. We looked at the file, the plan's contract and Medicare rules. The file shows you received outpatient mental health care provided by the social worker on August 15, 2019 and September 13, 2019. You have been asked to pay a $40 copayment for each visit. The outpatient mental health services fall within the Outpatient mental health care benefit category. This means that you have been asked to pay the correct amounts 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 outpatient mental health services provided on August 15, 2019 and September 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services provided on February 22, 2019 by an anesthesia assistant.You asked the Plan to pay for the anesthesia services. You say that these services were provided by anesthesia assistants which are payable by Medicare when supervised by a physician.The Plan denied your request. The Plan says that the claim was denied due to invalid provider.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. In this case, the Plan has not provided sufficient evidence to support non-payment of this claim. Anesthesiology assistants are Medicare eligible and no regulations were provided to indicate that this provider was not eligible in the State.Therefore, we decided that the Plan has to pay for the anesthesia services provided on February 22, 2019 by an anesthesia assistant.

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 for the compression stockings identified with code A6534 that were issued on September 25, 2019.You asked the Plan to pay for the compression stockings. You say that your doctor says you require these stockings for surgery because you are prone to blood clots.The Plan denied your request. The Plan says gradient compression stockings A6534 are non-covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 are non covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6534 that were issued on September 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fora cystourethroscopy (52234) provided February 19, 2019.You asked the Plan to pay fora cystourethroscopy. You say that you would like reconsideration based on the medical records provided.The Plan denied your request. The Plan says the billed service is 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.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 a cystourethroscopy. Our reviewer says that the cystourethroscopy (52234) is not supported by the medical records in this case. Our physician reviewer found the medical records provided do not contain documentation on a bladder tumor size 0.5 up to 2.0, asrequired by the code definition, therefore, CPT code 52234 is not eligible for reimbursement consideration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cystourethroscopy have not been met. Therefore, we decided that the Plan does not have to pay fora cystourethroscopy (52234) provided February 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on April 2, 2019 by out of network provider, "the hospital".You asked the Plan to pay forthe electrocardiogram. You say that services were medically necessary.The Plan denied your request. The Plan says services were non-emergent and there were network providers available who could provide the same service.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 2, 2019 by out of network provider, "the hospital".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone density test provided on February 6, 2019 by the out of network provider.You asked the Plan to pay forthe x-ray. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says there is no evidence the services were urgent or 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 urgent care and pre-approved care.The 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 bone density test provided on February 6, 2019 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on September 24, 2019.You asked the Plan to waive the copayment for the colonoscopy. You say that you were not aware you would have to pay because of a Cologuard test. You say that you have never had to pay for colonoscopies.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 $300 for each Medicare-covered outpatient admission to an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $300 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 colonoscopy with biopsy 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 acontractual 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 September 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal cord implantation procedure provided on July 9, 2019.You asked the Plan to waive the copayment for the spinal cord implantation procedure. You say that you cannot afford this copayment because you are on a fixed income and have multiple copayments you are currently paying down. 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 $275 copayment for Basic plan members per visit for outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $275 copayment for the spinal cord implantation procedure. The spinal cord implantation procedure falls within "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe spinal cord implantation procedure on July 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for extracapsular cataract removal provided by the physician on May 15, 2019.
You asked the Plan to waive the coinsurance for extracapsular cataract removal. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received extracapsular cataract removal provided on May 15, 2019. The allowed amount is $614.24 and 20% of that is $122.85. You have been asked to pay the total coinsurance amount of $122.85 for extracapsular cataract removal. Extracapsular cataract removal falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 extracapsular cataract removal provided by the physician on May 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) with sleeve (L2397) provided by the practice on January 16, 2019.
You asked the Plan to pay for the orthoses. You say that the supplies provided were medically necessary and should be covered by the plan. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, no claims submitted for evaluation and management service and no evidence of a prior telemedicine service with the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) with sleeve (L2397) provided by the practice on January 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe lab services provided to the enrollee on July 17, 2019.You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis was routine care and not authorized.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 inthis 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 Plandoes not haveto pay forthe lab services provided on July 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services. You asked the Plan to waive the copayment for the ambulance services. You say that you received a bill for an ambulance ride you did not need. Your wife was willing to drive but the hospital said you had to go in the ambulance. The Plan denied your request. The Plan says you were charged this costsharing 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 $200 copayment once per date of service no matter how many trips you make on that day for both ground and air ambulances. You had 1 ambulance trip(s). The Plan charged you $200 for these services. 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 services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown provided on August 15, 2019.You asked the Plan to pay for the crown. You say that the physicians office was in contact with the Plan prior to the procedure. You also say that at that time, you were assured payment for the procedure, less your 50% coinsurance.The Plan denied your request. The Plan says this service was considered up to 50% of the Medicare allowable fee of $745, which left you responsible for the total co-insurance of $372.50.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only obligated to pay a 50% cost share for endodontic, periodontic, and oral surgery dental services. The record shows that the Plan paid for 50% of the crown and you are responsible for the remaining 50%.Therefore, we decided that the Plan does not have to pay forthe crown provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 15, 2019 by out of network provider.
You asked the Plan to pay for office services. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and these services could have been obtained within the Plan 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 the medical services provided on July 15, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the extraction (D7140), and the bone replacement graft for ridge preservation (D7953) provided on April 1, 2019.
You asked the Plan to reimburse you for the dental services. You say that you were never advised that the services were not covered. The Plan denied your request. The Plan says the dental services are not listed as covered services.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the extraction (D7140), and the bone replacement graft for ridge preservation (D7953) provided on April 1, 2019.