Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from June 13, 2019 to December 7, 2019.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told that the supplies were 100% covered. 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 DME and related supplies. You received DME and related supplies from June 13, 2019 to December 7, 2019. The total allowed amount is $417.74 and 20% of that is $83.54. You have been asked to pay the total coinsurance amount of $83.54 for DME and related supplies. DME and related supplies falls within the DME and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from June 13, 2019 to December 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physical therapy and occupational therapy provided from June 1, 2019 through June 12, 2019.
You asked the Plan to waive the coinsurance for physical therapy and occupational therapy. You say that you asked multiple times to have him released. You say that the cost should be reviewed. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for skilled nursing care at an out-of-network skilled nursing facility. Covered services include physical therapy, occupational therapy and speech therapy. The enrollee has been asked to pay $156.56, which is 20% of the allowed amount for the physical therapy and occupational therapy. The allowed amount is $782.65 (20% x $782.65 = $156.65). The physical therapy and occupational therapy fall within the "Skilled nursing facility (SNF) care" 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 coinsurance for physical therapy and occupational therapy provided from June 1, 2019 through June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered DME items provided to the enrollee on October 15, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the items are not covered under Medicare or the Health Plan.
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 DME have not been met. The non-covered DME is not covered by the Plan or Medicare. Therefore, we decided that the Plan does not have to pay for non-covered DME items provided to the enrollee on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hydration intravenous infusion services coded 96360 provided on October 9, 2019.You asked the Plan to pay forthe hydration intravenous infusion services. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services billed are not supported by the documentation.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 96360 is intravenous infusion, hydration; initial, 31 minutes to 1 hour.We find that CPT code 96360 is not supported in the medical record. Specifically, the documentation does not include documentation of the time over which the infusion was administered. Based on this information, we decided that Medicare rules for coverage of the hydration intravenous infusion services have not been met.Therefore, we decided that the Plan does not have topay forthe hydration intravenous infusion services coded 96360 provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forextraspinal chiropractic manipulation (98943) and manual therapy (97140) provided by a chiropractor from October 15, 2019 to November 1, 2019.You asked the Plan to pay forextraspinal chiropractic manipulation and manual therapy. You say that you were not informed that these services would not be covered.The Plan denied your request. The Plan says these services are not covered by Medicare of 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 forextraspinal chiropractic manipulation (98943) and manual therapy (97140) provided by a chiropractor from October 15, 2019 to November 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction of benign lesions (17110) provided on October 7, 2019.
You asked the Plan to waive the copayment for the destruction of benign lesions. You say that this was not a surgery. The Plan denied your request. The Plan says this procedure is considered a surgery and 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 $125 copayment for each Medicare-covered outpatient hospital facility visit for outpatient surgery. You have been asked to pay a $125 copayment for the destruction of benign lesions. This procedure is considered to be an outpatient surgery. 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 destruction of benign lesions (17110) provided on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 8, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy services provided by Physicians Home Health and Infusion from October 16, 2019 to October 23, 2019.You asked the Plan to pay forhome infusion therapy services. You say that on the Centers for Medicare and Medicaid Services (CMS) website, this is listed as a valid code.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this code is not valid for Medicare purposes and is not payable.The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy services provided by Physicians Home Health and Infusion from October 16, 2019 to October 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from October 3, 2019 through October 31, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that you were informed your copayment would be $0. The Plan denied your request. The Plan says the copayments 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 $40 copayment for in-network, Medicare-covered physical therapy. You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is $320 ($40/visit x 8 visits = $320). Physical therapy falls 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 copayment for physical therapy provided from October 3, 2019 through October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tint, photochromatic, per lens (V2744) provided on November 5, 2019.You asked the Plan to pay for the lenses. You say that you needed glasses after cataract removal and that you needed tinted glasses because the sunlight bothers your eyes.The Plan denied your request. The Plan says the items is not covered under Medicare or the Health Plan.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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. The Tint, photochromatic upgrade is explicitly listed as not covered under the Vision Care benefit in the EOC.Therefore, we decided that the Plan does not have to pay for tint, photochromatic, per lens (V2744) provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 28, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2019 through September 15, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the documentation provided, it is my opinion that this hospitalization qualifies for inpatient payment under the two-midnight rule. The enrollee was evaluated in the emergency department (ED) on September 12, 2019 for failure to thrive. She was found to have hypokalemia and a UTI. Due to the presence of a ureteral stent, her UTI would have been considered complicated. As such, it was reasonable to believe that two midnights of care would be required to further evaluate and treat her. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 12, 2019 through September 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewing x-rays (CPT Code D0274) provided on October 29, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered because the provider was in-network with your health plan. The Plan denied your request. The Plan says the service is not a covered benefit under the 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 covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for bitewing x-rays (CPT Code D0274) provided on October 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 19, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for the copayment because the CT scan was not necessary. 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 $225 copayment for each in-network Medicare-covered advanced imaging service (not including x-rays). You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you received the CT scan during your emergency room 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 CT scan provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stays provided from August 17, 2019 to September 11, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stays . You say that you do not agree with the two different copayments. You say you would like the claims to be reprocessed to only reflect one 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 $175 copayment per day, days 1 to 7 at an in-network inpatient hospital. You have been asked to pay a total of $2,275 for the inpatient hospital stays. The inpatient hospital stays fall within the "Inpatient hospital care" benefit category. See chart below.
Dates of Service
Service
Copayment per Day
Number of Days
Member Liability
August 17, 2019 to August 23, 2019
Inpatient care
$175
6
$1,050
August 23, 2019 to September 11, 2019
Inpatient psychiatric care
$175
7
$1,225
Total
$2,275
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 reduce the copayment for the inpatient hospital stays provided from August 17, 2019 to September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit and echocardiograms provided on October 7, 2019 and October 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese out of network services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received 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 forthe office visit and echocardiograms provided on October 7, 2019 and October 9, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 9, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment per specialist visit. You had a specialist visit on December 9, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $44.09, which is less than the $45 copayment. You have been asked to pay $44.09 for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on December 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on November 20, 2019.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were not informed of 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 $275 copayment for nuclear medicine. You have been asked to pay a $275 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on November 19, 2019 and billed under code 80307.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided did not include documentation of the method of testing utilized to support the billed code; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on November 19, 2019 and billed under code 80307.