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

We decided that the Plan does not have to waive the copayment for the outpatient surgery rendered on December 11, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $245 copayment for outpatient surgery at an in-network ambulatory surgical center.
Review of the file shows that the enrollee received outpatient surgery services on December 11, 2019. The enrollee has been asked to pay a $245 copayment for these services. These services fall within the outpatient surgery at an in-network ambulatory surgical center 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 for the outpatient surgery rendered on December 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 26, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that this is the sole psychiatrist called in by the
facility to treat the patients and cannot refuse treatment. The Plan denied your request. The Plan says the
member's assisted living facility is out-of-network. The Plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on October 26, 2019
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessories including an expandable controller, harness, and connector (E2313, E2311, E2377).
You asked the Plan to pre-approve the wheelchair accessories. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 wheelchair accessories. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided do not support that the added controller features are medically necessary. 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 wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessories including an expandable controller, harness, and connector (E2313, E2311, E2377).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (CPT Code 99232) provided to the enrollee on October 29, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says that this service is included in another service provided to you at the same time by the same 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. It appears that the plan's contracted delegate did not provide sufficient information that would verify another service has been paid. Therefore, we decided that the Plan has to pay for subsequent hospital care (CPT Code 99232) provided to the enrollee on October 29, 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 copayment for the office visit provided on December 10, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were seen for you routine physical which has a benefit of $0 copayment and you should not have to pay the $20 copayment. 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 $20 copayment for the additional Medicare-covered services during a routine physical. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows diagnoses of mitral valve disorder, lipoprotein metabolism disorders, and fibroblastic disorders, in addition to the general examination.
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 December 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care
You asked the Plan to waive the copayment for SNF care. You say that the enrollee is being charged the wrong
amount. The Plan denied your request. The Plan says these services 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment per day for days 1 to 20 and a $172 copayment per day for for days 21 to 100 of
skilled nursing facility care.
The enrollee has been asked to pay a total of $2,408 for 34 days of SNF care ($0 for the first 20 days, $172 x
the remaining 14 days = $2,408). 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 for skilled
nursing facility (SNF) care
Your complaint about how the provider is billing the enrollee is not a valid appeal for medical coverage. This
part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a
decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 17, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
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 pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the duration of the trial with the basic device was not sufficient.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no unique characteristics such as failure to implement MLD and diuresis along with basic pump use for a reasonable outpatient trial period. At this time, a Flexitouch device is not medically necessary. There is mention of failing a basic pump, but the records do not indicate how long the trial period with basic pump use, was for. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator rental provided on December 17, 2019 by an out of network provider.
You asked the Plan to pay for the oxygen concentrator rental. You say that the oxygen concentrator was medically necessary. The Plan denied your request. The Plan says the clinical documentation is out of date.
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. There is no current documentation on medical necessity. 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 oxygen concentrator rental provided on December 17, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiology services provided on November 29, 2019.
You asked the Plan to waive the copayment for the radiology services. You say that you feel the enrollee 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 the enrollee received radiology services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per the enrollee's 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $195 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received radiology services on November 29, 2019. The enrollee has been asked to pay a $195 copayment for the radiology services. The radiology services fall within the Outpatient diagnostic tests 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 for the radiology services provided on November 29, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on December 18, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that the other drivers insurance should be responsible for 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 a $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ER visit provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy services (96413, 96415 and Q5103) provided
on November 12, 2019.
You asked the Plan to pay for the chemotherapy services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the billed 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 asked our coder 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 chemotherapy services. Our reviewer says that CPT
codes 96413, 96415 and Q5103 do not meet criteria for billing or reimbursement consideration. Our reviewer
found CPT codes 96413 and 96415 require a start and stop time. The documentation does not support the
modifier used for CPT code Q5103.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the chemotherapy services have not been met. Therefore, we decided that the
Plan does not have to pay for chemotherapy services (96413, 96415 and Q5103) provided on November 12,
2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 5, 2019 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without 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 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 November 5, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre Flash glucose monitoring system and sensors for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary, as it is designed to replace blood glucose testing for diabetes treatment decisions. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found no medical records have been submitted for review. Therefore, there is no documentation to support that the patient meets the coverage criteria for a CGM. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre Flash glucose monitoring system and sensors for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory services provided on December 27, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopy (44205) provided on October 21, 2019.
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration because this service is payable to an assistant surgeon. The Plan denied your request. The Plan says payment is not allowed because a Registered Nurse First Assistant is not recognized as a physician per Medicare Guidelines.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for a laparoscopy (44205) provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit on December 17, 2019 and
laboratory tests on December 24, 2019.
You asked the Plan to waive the cost share for the office visit and laboratory tests. You say that the entire bill
should be an annual wellness visit with no copayment. The Plan denied your request. The Plan says the cost
share 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 $25
copayment for medical care furnished by an in-network primary care physician and 20% coinsurance for each
in-network, Medicare-covered laboratory test.
You have been asked to pay a total of $35.82 for the office visit and laboratory tests.
Date of Service Service Allowed Amount Standard Cost Share Member Liability
December 17, 2019 Office Visit $68.05 $25 $25
December 24, 2019 Laboratory Tests $54.07 20% $10.82
TOTAL: $35.82
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The laboratory tests fall within the "Outpatient diagnostic tests and therapeutic services and supplies"
benefit category. The records show that the office visit and laboratory tests were diagnostic in nature. 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 cost share for the office visit on December 17, 2019 and laboratory tests on
December 24, 2019.