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

We decided that the Plan does not have to pay for the medical services provided on July 8, 2019 by out of network provider. You asked the Plan to pay for urology services. You say that you are appealing based on medical necessity.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, the attending provider is also out-of-network with the Plan, and the Plan did not authorize 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 for the medical services provided on July 8, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from July 31, 2019 through August 5, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that this stay should be a continuation of that admission because the hospitall was not equipped to do the ablation and pacemaker.The Plan denied your request. The Plan says the claims were processed accordingly with the member's 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). Review of the file show that the enrollee received inpatient hospital care from July 31, 2019 through August 5, 2019. Your EOC clearly states, enrollees must pay a $300 deductible per admission after the deductible is met. This means that the enrolleehas been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrolleeagreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee from July 31, 2019 through August 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care and an emergency department (ED) visit provided from June 4, 2019 to July 21, 2019 by "the hospital".You asked the Plan to waive the copayment forthe inpatient hospital care and ED visit. You say that you were not advised you would be liable for any charges associated with the services you received.The Plan denied your request. The Plan says based on Medicare billing criteria, the claims were billed 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 $285 copayment per day for days 1-7 for inpatient hospital care and a $90 copayment for emergency care. You have been asked to pay $2,085 for the inpatient hospital care and ED visit. $1,995($285x7) for the inpatient hospital care and $90 for the ED visit equals $2,085. 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 forinpatient hospital care and an emergency department (ED) visit provided from June 4, 2019 to July 21, 2019 by "the hospital".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital services provided from June 21, 2019 to June 23, 2019.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you had requested to make an appointment to come back and have the procedure done, but your request was denied. As such, you feel you should not be responsible for the copayment for the entire hospital stay.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $370 copayment per day for days 1-5 for inpatient hospital care. You have been asked to pay $1,110 for the inpatient hospital services. $370 per day for 3 days' equals $1,110. 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 forinpatient hospital services provided from June 21, 2019 to June 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 22, 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 codes 80156, 80157, 80177, 80201, 80162, 80159 and 80173 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.We find that CPT codes 80156, 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical record. Specifically, there is no laboratory report showing separate line item results for additional therapeutic drug levels and payment for these codes is included in the G0480 code, which was reimbursed. 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 laboratory services rendered on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on August 5, 2019.You asked the Plan to waive the copayment for the office visit. You say that you should not be charged a copayment when out of range.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 $15 copayment for provider and professional services at an in-network primary care physician's office.You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were seen for an office visit.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 office visit provided on August 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from July 19, 2019 through August 20, 2019.
You asked the Plan to waive the copayment for SNF care. You say that you had an extended stay at the facility due to falling from a chair that broke while being assisted in the shower. 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). Review of the file show that you received SNF care from August 8, 2019 through August 20, 2019. You are asked to pay a $150 copayment for days 21-32 of your SNF care. Your total cost-share is $1,800. 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 SNF care provided from July 19, 2019 through August 20, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for an ER visit provided from August 2, 2019 to August 3, 2019.You asked the Plan to waive the copayment for an ER visit. You say that you were admitted to the hospital and should not be responsible for the copayment.The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $120 copayment for emergency care. The ER copayment is waived if you are admitted to the hospital within 24 hours for emergency care.You state that you were admitted to the hospital following an ER visit. The plan did not provide medical records to prove otherwise. Therefore, you cannot be asked to pay the $120 copayment for ER services. The Plan says you must pay a $120 copayment for an ER visit. Based on the Plan contract, however, you cannot be asked to pay an ER copayment if you are admitted to the hospital within 24 hours.Therefore, we decided that the Plan has to waive the copayment for an ER visit provided from August 2, 2019 to August 3, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services provided from June 26, 2019 through July 25, 2019.

You asked the Plan to waive the copayment for the services. You say that you should not be responsible for any fees because the services should not have been performed. The Plan denied your request. The Plan says the claims were 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). 

Review of the file show that you received inpatient hospital care from June 26, 2019 through June 27, 2019. You are asked to pay a $225 copayment for one day of inpatient hospital care. You received basic radiology services on July 12, 2019. The Medicare-allowed amount for the basic radiology services is less than the set $200 copayment; therefore, you have been asked to pay the lesser amount of $58.06 for the services. Furthermore, you received advanced imaging services on July 25, 2019. You are asked to pay a $200 copayment for the services. Your total cost share responsibility is $483.06 ($225 + $58.06 + $200 = $483.06). 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 services provided from June 26, 2019 through July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) and ultrasound therapy provided on July 30, 2019 through August 1, 2019.You asked the Plan to pay for the office visit and ultrasound therapy. You say that you would like reconsideration because these services should be covered by the Plan. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit (99213) and ultrasound therapy provided on July 30, 2019 through August 1, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the copayment for eye exam. You say that this is the Plan's error and you should not have to pay for it.The Plan says that the copayment amount you are being charged is correct.We decided that the Plan has to reduce the copayment for eye exam. 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 each in-network eye exam.The Plan says that you must pay $50 copayment for in-network eye exam. Based on the Plan contract, however, you cannot be asked to pay more than $20 copayment for in-network eye exam. Therefore, we decided that the Plan has to reduce the copayment for eye exam from $50 copayment to $20 copayment. We also decided that the Plan does not have to waive the copayment for eye exam.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 in-network eye exam.Therefore, we decided that the Plan does not have to waive the copayment for eye exam.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for optometry services provided on July 9, 2019.You asked the Plan to pay for optometry services. You say that the provider does not accept your primary insurance, so this Medicare Plan should be responsible for payment of the claim.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan is your secondary payer insurance and cannot process this claim until the primary payer Explanation of Benefits (EOB) has been received.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways.First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted both the provider and your primary insurance carrier to obtain primary insurance payment information so that the claim can be processed. As the secondary insurer, the Plan cannot be held responsible for optometry services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay for optometry services provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 12, 2019.
You asked the Plan to pay for office visit. You say that this was a follow-up visit to the enrollee's hospital stay. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for an office visit provided on April 12, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for an emergency room visit provided from June 5, 2019 to June 6, 2019.
You asked the Plan to waive the copayment for emergency room visit. You say that you were admitted to the hospital and this was not an observation stay. You also say that you are not financially able to pay this amount. The Plan denied your request. The Plan says that the copayment amount you are being charged is correct.
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. The Plan did not submit medical records to support your patient status during this hospital stay. You say that you were admitted to the hospital, and submitted a Plan notice supporting that an inpatient hospital admission took place. Without medical records, we cannot determine whether you were admitted to the hospital within 24 hours of this emergency room visit, which would waive the copayment for the emergency room services. Therefore, the Plan has not shown that the $90 emergency room visit copayment you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for an emergency room visit provided from June 5, 2019 to June 6, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on May 29, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you have never been charged in the past 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 you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on May 29, 2019. The allowed amount is $2,150.50 an 20% of that is $430.10.You have been asked to pay the total coinsurance amount of $430.10 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 fora Medicare Part B drug injection provided on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on August 12, 2019.You asked the Plan to waive the copayment fo rthe eye exam. You say that you believed this provider was in network.The Plan denied your request. The Plan says that your 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 $30 copayment for an eye exam from an out-of-network provider. You have been asked to pay $30 copayment for the eye exam. The eye exam falls within the eye exam from an out-of-network provider 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 eye exam provided by the practice on August 12, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes (99239) provided by the physicians on May 30, 2019.
You asked the Plan to pay for hospital discharge day management. You say that the records provided should support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services to confirm Medicare coverage has been met.
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 find that CPT code 99239 is not supported in the medical record. Specifically a documented duration of time of 31 minutes or more is required to support this code. The submitted discharge summary does not support hospital discharge day management of more than 30 minutes. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes (99239) provided by the physicians on May 30, 2019.