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

We decided that the Plan does not have to waive the coinsurance forthe rheumatoid arthritis infusions March 51, 2019 to August 15, 2019.You asked the Plan to waive the coinsurance forthe rheumatoid arthritis infusions. You say that you cannot afford the $900 amount. You say you were told you had the best policy for your medical conditions, with no coinsurance and small payments.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 20% coinsurance for in-network Medicare-covered Part B chemotherapy and prescription drugs. You have been asked to pay $2,727.21 for the rheumatoid arthritis infusions. The rheumatoid arthritis infusions fall within the "Medicare Part B prescription drugs" benefit category. See chart below.Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityMarch 15, 2019Heparin in$4.7120%$0.94March 15, 2019Tocilizumab inj$4,497.2220%$899.44March 15, 2019Saline solution$31.6320%$6.33July 18, 2019Tocilizumab inj$4,467.1520%$893.43July 18, 2019Saline solution$31.6320%$6.33July 18, 2019Additional saline solution$9.3820%$1.88August 15, 2019Tocilizumab inj$4,573.4820%$914.70
Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityAugust 15, 2019Saline solution$15.9620%$3.19August 15, 2019Additional saline solution$4.8320%$0.97Total$2,727.21This 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 forthe rheumatoid arthritis infusions provided from March 51, 2019 to August 15, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit on September 18, 2018.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the out-of-network charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollee must pay 50% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You received a specialist visit with an out-of-network provider on Sepetember 18, 2018. The allowed amount is $107.34 and 50% of that is $107.34. The enrollee has been asked to pay the total coinsurance $107.34 for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 that the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit on September 18, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit (99213) provided by your doctor on July 15, 2019.
You asked the Plan to waive the copayment for an urgent care visit. You say that you should not be responsible for the $40 bill you received from the practice because on that day you did not see a specialist, nor did you see a physician. You state that you went in for a tick bite and the physician assistant looked at it and said you may need to see a physician if it didn't get better. The Plan denied your request. The Plan says urgently needed services have a $40 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 a $40 copayment for urgently needed services. You have been asked to pay a $40 copayment for an urgent care visit. This service falls within the urgently needed services 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 urgent care visit (99213) provided by your doctor on July 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered to you by the Medical Center on June 25, 2019 to June 28, 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). Your contract with the Plan clearly says that you must pay a $50 copayment for emergency care.
Review of the file shows that you received emergency room services from June 25, 2019 to June 28, 2019. You have been asked to pay a $50 copayment for these services. These services fall 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 the emergency room (ER) services rendered to you by the Medical Center on June 25, 2019 to June 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services rendered to the enrollee by the provider on August 14, 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 payment is included in the facility payment.
The Plan must follow Medicare rules. The rules say that the PC for diagnostic services is separately paid only when the services are performed in a different payment locality than the TC. We looked at the file and Medicare rules. The file shows that both the TC and PC of the services at issue were performed in the same payment locality. 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 pathology services rendered to the enrollee by the provider on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train-of-four (TOF) testing provided on December 1, 2018 billed with code 95999.
You asked the Plan to pay for the TOF testing. You say that all services should be paid as these were medically necessary to monitor the patient during the spinal surgery. The Plan denied your request. The Plan says TOF testing is integral to intraoperative neuromonitoring and cannot be separately reported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the medical record. Specifically, this type of testing is an integral component of neuromonitoring. As such, it is incorrect unbundling to report this portion of the monitoring separately. Based on this information, we decided that Medicare rules for coverage of the TOF testing have not been met. Therefore, we decided that the Plan does not have to pay for the train-of-four (TOF) testing provided on December 1, 2018 billed with code 95999.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), limited oral evaluation (D0140), core buildup (D2950), and crown (D2740) provided from June 10, 2019 to July 10, 2019.
You asked the Plan to pay for intraoral - periapical first radiographic image, limited oral evaluation, core buildup, and crown. You say that more than $550 should be reimbursed since the services were medically necessary. The Plan denied your request. The Plan says the benefit allowance has been exceeded. Therefore, coverage criteria has not been met.
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. The Plan covers $550 every year for non-Medicare covered comprehensive dental services. We looked at the file and Medicare rules. Specifically, the benefit allowance has been exceeded. Based on this information, we decided that the Plan's rules for coverage of intraoral - periapical first radiographic image, limited oral evaluation, core buildup, and crown have not been met. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220), limited oral evaluation (D0140), core buildup (D2950), and crown (D2740) provided from June 10, 2019 to July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services provided to the enrollee on June 26, 2019.
You asked the Plan to pay for the echocardiography 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 payable as 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 93306 is Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography. We find that CPT code 93306 is not supported in the medical record. Specifically, this code was billed with modifier 26 (professional component). This was previously processed and paid to a different provider. It is inappropriate to submit multiple claims for the professional component (modifier 26) of the same diagnostic test, as this service is performed once by a single provider. Based on this information, we decided that Medicare rules for coverage of the echocardiography services have not been met. Therefore, we decided that the Plan does not have to pay for the echocardiography services provided tothe enrollee on June 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) provided.
You asked the Plan to pay for the subsequent hospital care. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says the billed service did not include the appropriate primary, first-listed or principal diagnosis. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that when there is a "code first" note and an underlying condition is present, the underlying condition should be sequenced first, if known. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Specifically, the Primary Diagnosis in this case is G92. G92 is a "Code first" code, which means that the underlying condition should be sequenced first. In this case, the underlying conditions were known but were not sequenced first. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99232) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown, porcelain fused noble metal, (D2752) provided by on September 30, 2019.You asked the Plan to reimburse you for the dental service. You say that your wife was advised by a Plan representative that after 6 months, a crown would be covered with a $350 deductible. You say that the Plan representative did not mention that you would have to have a comprehensive plan.The Plan denied your request. The Plan says the enrollee was not enrolled in the supplemental comprehensive dental rider for an additional $25 per month premium. The Plan says the enrollee does not have this rider and did not have the rider on the date of service. The Plan also says that crowns are not listed as a covered service.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, crowns are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you for the crown, porcelain fused noble metal, (D2752) provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not see the doctor and should not pay the 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 $45 copayment for each in-network Medicare-covered visit with a specialist. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed by the physician and you saw the physician's assistant who works under his guidance.
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 specialist office visit provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that thePlan does not have to pay forresin based composite posterior teeth #19 and #30 and intraoral periapical x-rays provided July 22, 2019 to September 10, 2019.You asked the Plan to pay forthe fillings and dental x-rays. You say that you were not aware that the Plan does not cover white filings in the molars and you cannot afford to pay this amount.The Plan denied your request. The Plan says fillings for posterior teeth is not covered and the periapical x-rays exceeded the maximum allowed.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. The plan contract says that white fillings are covered on the anteriorteeth. Multiple x-rays were taken on the July 22, 2019 visit and the maximum number was paid for by the plan.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forresin based composite posterior teeth #19 and #30 and intraoral periapical x-rays provided July 22, 2019 to September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a face-down positioning device (E1399) provided on March 7, 2019 through April 12, 2019.
You asked the Plan to pay for the face-down positioning device. You say that this device was medically necessary for your recovery from surgery. The Plan denied your request. The Plan says this device is not a covered benefit under Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Per CMS guidelines, these types of devices are considered "precautionary devices" and also can be used for purposes other than the treatment of an illness or injury. Therefore, we decided that the Plan does not have to pay for a face-down positioning device (E1399) provided on March 7, 2019 through April 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient physical therapy visits provided by the Hospital from July 2, 2019 to July 19, 2019.
You asked the Plan to waive the copayments for physical therapy visits. You say that these services did not work as well as they should have, so you should not be responsible for copayments. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 copayment for each physical therapy visit. There were 5 visits, resulting in a total copayment obligation of $150. You have been asked to pay $30 copayment for each physical therapy visit. Physical therapy visits fall within the Outpatient Rehabilitation Services 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 copayments for outpatient physical therapy visits provided by the Hospital from July 2, 2019 to July 19, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the neck brace provided on June 11, 2019.You asked the Plan to pay forthe neck brace. You say that this is a covered item which was medically necessary for the enrollee. This should be paid by the plan.The Plan denied your request. The Plan says that this durable medical equipment was provided in the emergency room and is considered part of the payment made to the facility. No separate payment can be made.The Plan must follow Medicare rules. Medicare rules say that DME is covered by Medicare Part B when it is provided for use in the enrollee's home. In this case, the Plan provided no supporting evidence to confirm their rationale that this brace is not eligible for separate payment. This would be considered inclusive to facility payment only if provided during a Part A inpatient stay. However, the documentation supports that this was prescribed by the ED doctor for use in the home. This type of device is paid separately from the fee schedule when provided in this circumstance.Therefore, we decided that the Plan has to pay for the neck brace provided on June 11, 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 pay forthe office visit rendered to the enrollee by the provider on August 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says payment is included in the global surgical payment.The Plan must follow Medicare rules. The rules say that post-operative visits are included in the global surgical package.The services at issue are an office visit billed with code 99213. These services were billed within the global surgical period for code 43860 (revision of stomach-bowel fusion). Payment for this post-operative visit is included in the global surgical package.Therefore, we decided that the Plan does not have to pay forthe office visit rendered on August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora shower chair.You asked the Plan to pay fora shower chair. You say that your doctor advised you to get the bath seat because your legs get shaky in the shower. You say that without the bath seat you could fall and injure yourself.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pay fora shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe services provided to the enrollee by the provider on May 21, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere is no indication of any attempt to obtain 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 Plandoes not haveto pay forthe services provided on May 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided.