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

We decided that the Plan does not have to pay for an evaluation and management service (99213) provided on June 13, 2019.
You asked the Plan to pay for the evaluation and management service. You say that you would like reconsideration as the claim was billed correctly and the services were medically necessary. The Plan denied your request. The Plan says the -57 modifier has been used incorrectly.
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 99213 25 57 is not supported in the record. Specifically, a -57 modifier may not be used on an evaluation and management visit billed on the day of or the day before a procedure with a 0 or 10-day global period. Based on this information, we decided that Medicare rules for coverage of the evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for an evaluation and management service (99213) provided on June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on August 5, 2019.
You asked the Plan to waive the copayment for an office visit. You say that your parents were never notified about any additional costs that would be applied to the office visit. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $5 copayment for physician/practitioner services/in-network/provider and professional services/PCP's office. The enrollee has been asked to pay a $5 copayment for an office visit. The correct copayment has been applied for the office visit that was provided. An office visit falls within the physician/practitioner services/in-network/provider and professional services/PCP's office 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 an office visit provided on August 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe paramedic intercept services.You asked the Plan to pay forthe paramedic intercept services. You say that the paramedic intercept services were medically necessary. You say that the ambulance service where you live does not provide paramedic services and that if you had not had those services your health would have been seriously compromised.The Plan denied your request. The Plan says this item is not a covered benefit.The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay forthe paramedic intercept services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ambulance trip provided on June 24, 2019.
You asked the Plan to waive the deductible for an ambulance trip. You say that you do not think that a deductible should be applied to an ambulance service. You say that you have a lot of other medical bills and you cannot afford this bill. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible for ambulance services. The item or service you asked the Plan to waive the deductible for falls within the benefit category ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for ambulance services. This cost sharing is a contractual obligation that had not been met at the time an ambulance trip was received on June 24, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an ambulance trip provided on June 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on August 15, 2019 by the out of network provider.You asked the Plan to pay forthe wound care services. You say that the provider is the only wound specialist that works for the nursing home. You say that the provider treated theenrollee under the impression there was an authorization on file.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.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 provider in this case is not a network provider with the Plan. The referring facility is not a network provider with the Plan. The Plan has networkproviders 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 subsequent nursing facility care provided on August 15, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for anesthesia services (00537) and arterial catheterization (36620) provided on August 21, 2019.
You asked the Plan to waive the coinsurance for the anesthesia and arterial catheterization. You say that you received a bill from the provider for a denied service which you are not responsible for. The Plan denied your request. The Plan says you are responsible for 20% coinsurance for outpatient surgery services.
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 outpatient surgery. You have been asked to pay 20% coinsurance for the anesthesia and arterial catheterization. the anesthesia and arterial catheterization 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 coinsurance for anesthesia services (00537) and arterial catheterization (36620) provided on August 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the air ambulance supplies provided on July 14, 2019.
You asked the Plan to pay for the air ambulance supplies (A0999). You say that the services were medically necessary. The Plan denied your request. The Plan says supplies are considered part of the general ambulance service and payment is included in the payment rate for the transport.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the air ambulance supplies (A0999) have not been met. Therefore, we decided that the Plan does not have to pay for the air ambulance supplies provided on July 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto waive the coinsurance for cataract surgery (66984) and a glucose assay (82947) provided by the hospital on July 22, 2019.You asked the Plan to waive the coinsurance for the cataract surgery. You say that you should not be responsible for the coinsurance because the surgery was not completed. The Plan denied your request. The Plan says you are contractually obligated to pay a coinsurance for an in-network service received in an outpatient setting.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 outpatient surgery and a $15 copayment for laboratory services. You have been asked to pay $440.18 for the cataract surgery. The allowed amount for this service is $2,200.91. 20% of $2,200.91 is $440. 18. The correct coinsurance has been applied. You have been asked to pay $0.87 for laboratory services. This is less than the $15 copayment outlined in the Plan's 2019 EOC.You have been asked to pay 20% coinsurance for the cataract surgery. You have also been asked to pay less than the contracted amount for laboratory services. The cataract surgery and glucose assay fall 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 coinsurance for cataract surgery (66984) and a glucose assay (82947) provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewings, prophylaxis, and topical application of fluoride provided on September 24, 2019.
You asked the Plan to pay for the dental services. You say that you are insured. The Plan denied your request. The Plan says the provider that you received these dental services from is not a network provider.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, each additional intraoral periapical x-ray, bitewings, prophylaxis, and topical application of fluoride provided on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of skin lesion, surgical pathology, inhalation treatment, non-invasive ear or pulse oximetry, and 8 injections provided on March 22, 2019 by the out of network provider.
You asked the Plan to pay for the outpatient surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The referring providers are not network providers either. 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 excision of skin lesion, surgical pathology, inhalation treatment, non-invasive ear or pulse oximetry, and 8 injections provided on March 22, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on August 9, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that this was a screening for lung cancer not a diagnostic exam. You say that you should be reimbursed.The Plan denied your request. The Plan says the copayment 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 advanced imaging services at an in-network specialist's office.You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. A CT scan is considered diagnostic imaging. 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 forthe CT scan provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 3, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you could not see your primary care physician. You say that you did not expect the higher copayment.The Plan denied your request. The Plan says the copayment 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 $35 copayment per visit for a specialist. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider specializes in Geriatrics. 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 forthe office visit provided on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 20, 2019 by out of network provider, "the provider".You asked the Plan to pay fordrug testing. You say that most in-network providers cannot perform this testing, and the referring physician is a contracted provider who has been reimbursed for services.The Plandenied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician "the doctor". is also out-of-network with 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 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 20, 2019 by out of network provider, "the provider".
Appeal type: Surgery
Decision: Unfavorable

We decided that thePlan does not have to pay for the assembly and operation of a pump (99190) provided on July 29, 2019.You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to an hour to set up the Heart Lung Machine. The perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is included in the DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules saythat 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, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine provided on May 6, 2019.You asked the Plan to pay fora shingles vaccine. You say that this is covered by Medicare.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine. The Plan follows the same rules. Records do not showthat you have been injured or directly exposed to any illness related to a shingles vaccine.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine provided on May 6, 2019.Benefits for a shingles vaccinemay beavailable under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CPAP supplies provided on July 10, 2019.You asked the Plan to waive the coinsurance forthe CPAP supplies. You say that you want to know why insurance and you have been charged for the CPAP supplies.The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Durable Medical Equipment and Related Supplies. You have been asked to pay 20% coinsurance for the CPAP supplies. the CPAP supplies falls within the Durable Medical Equipment 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 forthe CPAP supplies provided on July 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on July 16, 2019.
You asked the Plan to pay for drug test. You say that you are submitting a test requisition for this test and the documents support the code billed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records signed by the ordering physician to support this test.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab test billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 10, 2019.You asked the Plan to waive the copayment forthe office visit. You say that this was an annual physical. You say this should be $0.The Plan denied your request. The Plan says the copayment 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 $0 copayment for an annual physical by your primary care provider (PCP). If, during the physical exam, you also receive services to treat a medical condition, you will be expected to pay a $20 copayment for the additional, Medicare-covered services. 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 records show that your current medical conditions were discussed during the office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe office visit provided on September 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the colonoscopy and the tissue exam on August 28, 2019.
You asked the Plan to waive the copayments for the colonoscopy and the tissue exam. You say this is a free, diagnostic service and should not be charged a 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 $125 copayment for each in-network Medicare-covered ambulatory surgical center visit and a $35 copayment per day, per provider for in-network Medicare-covered pathology services.
You have been asked to pay a $125 copayment for the colonoscopy and a $35 copayment for the tissue exam. ($125 + $35 = $160). The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The tissue exam falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical records show the colonoscopy was ordered due to blood in the stools. Therefore, the colonoscopy was 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 copayments for the colonoscopy and the tissue exam on August 28, 2019.