Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyeglasses provided on August 16, 2019.You asked the Plan to pay forthe eyeglasses. You say that some of the price should be covered.The Plan denied your request. The Plan says that you do not have an out of network benefit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers eyeglasses at a network optical provider .We looked at the file and the Plan's rules. The file indicates the eyeglasses were not purchased from a network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay forthe eyeglasses provided on August 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided from October 2, 2019 through October 3, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were not given a semi private room, you were in the hallway in the basement of the hospital after your replacement surgery.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 from October 2, 2019 through October 3, 2019. You are asked to pay a $275 copayment for the one (1) day of inpatient hospital care. 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 provided from October 2, 2019 through October 3, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran Emergency Room Visit (99281) provided on July 16, 2019 by "the provider". You asked the Plan to waive the copayment forthe Emergency Room Visit. You say that the hospital care was poor and the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied for the service at issue.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 $73.06 copayment for the Emergency Room Visit. The Emergency Room Visit falls within the Emergency Care benefit category. In this case, the Medicare allowed amount of $73.06 was less than the $90 copayment stipulated in the contract. 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 foranEmergency Room Visit (99281) provided on July 16, 2019 by "the provider".
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the inpatient hospital care provided by "the hospital" from July 19, 2019 to July 22, 2019.

You asked the Plan to adjust the copayment. You say that you are requesting reconsideration of the Plan's denial to make sure the insurance has been processed appropriately. The Plan denied your request. The Plan says the $530.00 copayment applied correctly. Cost sharing is a contractual obligation under the plan and cannot be waived.

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 $265 copayment each day, for days 1-8 for inpatient hospital care. 

You have been asked to pay a $530 copayment ($265 x 2 days) for inpatient hospital care. 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 adjust the copayment for the inpatient hospital care provided July 19, 2019 to July 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forinjection and infusion pump services (HCPCS J1170 and A4220) provided to the enrollee on June 14, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says J1170 is excluded from the physician fee schedule, and A4220 is a bundled code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that the denied codes are not supported in the medical record. Specifically J1170 is specifically an excluded code, and A4220 cannot be billed separately from CPT 62370, which was already paid for. 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 forinjection and infusion pump services (HCPCS J1170 and A4220) provided to the enrollee on June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forDiabetic Testing Supplies (A4253, A4259, A4256, A4235) provided August 12, 2019 to October 31, 2019.You asked the Plan to pay forthe Diabetic Testing Supplies. You say that the items were medically necessary.The Plan denied your request. The Plan says valid proof of delivery was not submitted for the items at issue.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the Proof of Delivery is not itemized to indicate the specific supplies and contained no tracking or order number for verification.Therefore, we decided that the Plan does not have to pay forDiabetic Testing Supplies (A4253, A4259, A4256, A4235) provided August 12, 2019 to October 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided to the enrollee from August 22, 2019 through September 13, 2019, by an out-of-network provider.You asked the Plan to waive the copayment forSNF care. You say that Original Medicare covers the first twenty days of a SNF stay withno beneficiary cost-share remaining.The Plan denied your request. The Plan says the claim was 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). The Plan is required to administer benefits equally to all of its members according to the EOC. The Plan accurately applied a 20% coinsurance to eligible charges for enrollee's August 22, 2019 through September 13, 2019 stay at the facility. The EOC states, the member will be assessed a 20% coinsurance when services are performed at an out-of-network SNF. This means that the enrollee has been asked to pay the correct amount based on the contractwith 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 forSNF care provided to the enrollee from August 22, 2019 through September 13, 2019, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatienthospital care provided from March 20, 2019 through March 26, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plandenied 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 shows that you were admitted on March 20, 2019 and discharged on March 26, 2019. You were asked to pay a $370 copayment per day from March 20, 2019 through March 25, 2019, days 1-5 of your inpatient hospital care. You were discharged on March 26, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $370 copayment per day required for days 1-5. 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 provided from March 20, 2019 through March 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurological monitoring performed during multilevel lumbar spinal decompression surgery (95999) provided to the enrollee on November 27, 2018.You asked the Plan to pay forthe services. You say that the services are medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Your condition did not meet the Medicare rules for approval of train of four (testing to monitor the depth of muscle relaxation during surgery) (95999 Unlisted neurological or neuromuscular diagnostic procedure (As per records: TRAIN OF FOUR).  The record sent by your provider indicates that you required neurophysiology monitoring for surgery.Under Medicare rules, the request is not a covered benefit. This service, train of four, is considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled payment. You will not be held responsible for this payment.Therefore, we decided that the Plan does not have to pay forintraoperative neurological monitoring performed during multilevel lumbar spinal decompression surgery (95999) provided to the enrollee on November 27, 2018
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required, and a porcelain or ceramic crown.You asked the Plan to pre-approvethe core buildup and crown. You say that your current crown is damaged and needs to be replaced.The Plan denied your request. The Plan says these services are not covered under your benefit plan.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 requested items or services are not among those coveredunder this benefit.Therefore, we decided that the Plan does not have to pre-approvea core buildup, including any pins when required, and a porcelain or ceramic crown
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 12, 2019 by out of network provider.You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the enrollee has no out-of-network benefits and there are providers in-network that could provide the services at issue.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 August 12, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for(CPT Code E0431) and (CPT Code E1390) provided by an in-network providerfrom February 28, 2019 through August 28, 2019.You asked the Plan to waive the coinsurance forthe DME. You say that you are being charged $32.38 per month for oxygen. You stated that Medicare limits the charge to $18.50 which is what you state you have always paid.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 ascopayments, deductibles and coinsurance). Review of the file show that you received DME provided by an in-network providerfrom February 28, 2019 through August 28, 2019. You are asked to pay 20% coinsurance per date of service for the DME. The cost share was applied correctly per your benefit and is calculated by taking the Medicare-allowed amount and multiplying it by 20%. 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(CPT Code E0431) and (CPT Code E1390) provided by an in-network provider from February 28, 2019 through August 28, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora left shoulder aspiration with fluoroscopy provided on August 16, 2019.You asked the Plan to waive the copayment fora left shoulder aspiration. You say that you should not have to pay a copayment because the procedure had to be done twice.The Plan denied your request. The Plan says this service processed correctly.The rules say a plan must disclose to its enrollees inclear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for outpatient surgery. You have been asked to pay a $125 copayment for a left shoulder aspiration. Aleft shoulder aspiration falls within the outpatient surgery 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 fora left shoulder aspiration with fluoroscopy provided on August 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Stent Placement performed on September 4, 2019.You asked the Plan to waive the coinsurance forthe Stent Placement. You say that the procedure only took 5 hours and the coinsurance is too high.The Plan denied your request. The Plan says the correct coinsurance wasapplied per the 2019 EOC.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 10% coinsurance for Outpatient Surgical Services. You have been asked to pay a 10% coinsurance for the Stent Placement. The Stent Placement falls within the Outpatient Surgical 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 coinsurance fora Stent Placement performed on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay fora Tetanus Vaccination (90715, 90472) provided September 12, 2019 by "the doctor". You asked the Plan to pay forthe vaccination. You say that you did not know the shot would not be covered.The Plan denied your request. The Plan says coverage for the vaccine must be submitted through the Part D benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccination.Therefore, we decided that the Plan does not have to pay fora Tetanus Vaccination (90715, 90472)provided September 12, 2019 by "the doctor". Benefits for the vaccinationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) (G6015).You asked the Plan to pre-approve IMRT. You say that the services are medically necessary.The Plan denied your request. The Plan says medically necessary care associated with a clinical trial is paid by Medicare directly, not the health plan.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 IMRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found as more studies are needed to establish hippocampal sparing as a superior alternative to standard whole brain radiation for patients with brain metastases from small cell lung cancer, coverage criteria are not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met.Therefore, we decided that the Plan does not have to pre-approveIntensity Modulated Radiation Therapy (IMRT) (G6015)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wrist hand finger orthosis (CPT Code L3807) provided on September 17, 2019.You asked the Plan to waive the coinsurance forthe DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says theclaim 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 youreceived DME on September 17, 2019. You are asked to pay 10% coinsurance for the DME. 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 forwrist hand finger orthosis (CPT Code L3807) provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 4, 2019.You asked the Plan to pay forthe medical services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plansays the enrollee enrolled in hospice from May 16, 2018 through November 6, 2019. The plan states, per Medicare guidelines, the provider needs to bill Original Medicare for the services rendered on June 4, 2019.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe medical services provided on June 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory drug testing services provided on October 30, 2019.You asked the Plan to pay for the laboratory drug testing services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot beprovided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory drug testing services provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Rituxan (J9312) provided on August 16, 2019.You asked the Plan to waive the coinsurance forthe Rituxan (J9312). You say that you feel you should not be responsible for this cost share amount. You say that you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received a Medicare Part B drug on the date of service at issue in this appeal. The plan states the correct coinsurance 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 20% coinsurance for Medicare Part B Prescription Drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows you received Rituxan (J9312) on August 16, 2019. You have been askedto pay a 20% coinsurance for the Rituxan (J9312), totaling $1899.46. The Rituxan (J9312) 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 forthe Rituxan (J9312) provided on August 16, 2019.