Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for inpatient stay. You say that you did not stay in the hospital overnight, so you should only be charged the $125 outpatient surgery copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is 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 $300 copayment for inpatient stay. Although you may not have stayed in the hospital overnight, your patient status for this stay was inpatient and therefore the inpatient copayment applies to this claim.

You have been asked to pay $300 copayment for inpatient stay. Inpatient stay falls within the Inpatient Hospital Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you did not need authorization previously. The Plan denied your request. The Plan says this provider is out-of-network. The Plan says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive hearing exam (92557).

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the claim was reprocessed by the Plan and the copayment has been applied correctly to the service provided.

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 $39 copayment for Medicare-covered hearing exams provided by an in-network provider. Additionally, you pay a $0 copayment for routine hearing exams.

You have been asked to pay a $39 copayment for the Medicare-covered hearing exam rendered by an in-network provider. The record indicates that you were seen by a specialist for a complaint of tinnitus and not for a routine hearing exam. 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 comprehensive hearing exam (92557).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the unspecified preventive procedure (D1999).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says a limited oral evaluation is not a covered benefit under your dental policy. Additional payment cannot be issued for the unspecified preventive procedure as participating providers receive a monthly stipend for this 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, the limited oral evaluation provided is not among those services covered under this benefit. Additional payment cannot be issued for the unspecified preventive procedure as participating providers receive a monthly stipend for this service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the unspecified preventive procedure (D1999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Computed Tomography (CT) scan of the thorax (71250).

You asked the Plan to waive the copayment for the CT scan. You say that you had the same screening a year ago and did not have a copayment, and the bill was submitted with the incorrect service. You say that the service provided was a lung cancer screening. The Plan denied your request. The Plan says the provider billed code 71250, which is not the same as a lung cancer screening. The CT scan that was provided has a $200 copayment after you meet your deductible, and at the time of the service your deductible had not been met.

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 $200 copayment for advanced imaging services after your $750 deductible is met.

The scan was billed as a CT scan of the thorax and not as a lung cancer screening. It is the responsibility of the provider to bill for the correct services. The item or service you asked the Plan to waive the copayment for falls within the advanced imaging services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $200 copayment after your $750 deductible is met for advanced imaging services. The amount you have been asked to pay is equal to or less than this amount, and that cost was applied to your deductible. This cost sharing is a contractual obligation that had not been met at the time the CT scan was received. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan of the thorax (71250).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for lab test. You say that your right to payment is not extinguished by Plan requirements such as network participation. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee was not referred by an in-network provider.

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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs (A9270).

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the self-administered drugs provided in the outpatient hospital setting are not payable under your contractual policy or by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs provided are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs (A9270).

Benefits for these items may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital clinic and surgical services.

You asked the Plan to waive the copayment for outpatient hospital visit. You say that you refuse to pay for use of the facility. The Plan denied your request. The Plan says the copayment amount you are being charged is 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 $250 copayment for outpatient hospital visit.

You have been asked to pay $200.62, which is less than the $250 copayment for outpatient hospital visit. Outpatient hospital visit falls within the Outpatient Surgery, Including Services Provided at Hospital Facilities and Ambulatory Surgical Centers 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 outpatient hospital clinic and surgical services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI of the brain stem (70553).

You asked the Plan to pay for the MRI. You say that you would like reconsideration because this service was rendered in the appropriate place of service. The Plan denied your request. The Plan says the member was impatient on the billed date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 70553 is not supported in the record. Specifically, the record indicates that the member was registered inpatient on the billed date of service. When a member is registered inpatient, the physician must report the inpatient hospital POS code 21. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for MRI of the brain stem (70553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an optical procedure.

You asked the Plan to pay for an optical procedure. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an optical procedure.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pharmacogenetic testing.

You asked the Plan to pay for the testing services. You say that the pharmacogenetic testing can increase the safety of prescribing medication. The Plan denied your request. The Plan says that Medicare denies coverage for all cardiovascular risk assessment testing, except the basic lipid panel.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The records in the case file do not show that the enrollee received cardiovascular risk assessment testing. The Plan did not provide relevant Medicare rules to show the services provided are not covered in this case. Therefore, we decided that the Plan has to pay for the pharmacogenetic testing.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires (A4557) for a TENS unit.

You asked the Plan to pay for lead wires. You say that the item was medically necessary. The Plan denied your request. The Plan says per CMS Local Coverage Determination (LCD) L33802 "Replacement of lead wires more often than every twelve months would rarely be reasonable and necessary." Since a TENS unit has been purchased in the previous twelve months, the lead wires have been denied.

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 pay for lead wires. Our reviewer says that the requested items is not considered medically reasonable and necessary in this case. Our physician reviewer found there was no indication within the records provided as to why the member required a replacement lead wire. Consequently, it cannot be determined that this item would have been reasonable and necessary at the time it was provided.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lead wires have not been met. Specifically, the enrollee has already received lead wires. There is no evidence that it was medically necessary or reasonable to replace them within twelve months of the original order. Therefore, we decided that the Plan does not have to pay for lead wires (A4557) for a TENS unit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective coating, per lens (V2750) and the polycarbonate, per lens (V2784).

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not a covered benefit under your contractual policy.

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 these items have not been met. Specially, the Plan contract states that covered eyewear does not include lens options. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating, per lens (V2750) and the polycarbonate, per lens (V2784).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is out-of-network.

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 had network providers available who could have provided 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 lab work provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveAvastin.You asked the Plan to pre-approveAvastin. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria hasnot been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Avastin. Our reviewer says that the medication is medically necessary. Our physician reviewer found the clinic proceedings are medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Avastin have been met.Therefore, we decided that the Plan has to pre-approveAvastin.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Paramedic on February 18, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 18, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by THE Paramedic on February 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD.

You asked the Plan to waive the copayment for an EGD. You say that you disagree with the charges because you were told that you would not owe a copayment. 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 $175 copayment for outpatient surgery, including services provided at ambulatory surgical centers.

You received an EGD. An EGD is considered an outpatient surgical procedure and is subject to cost-sharing charges. Therefore, you are responsible to pay the $175 copayment.

You have been asked to pay a $175 copayment for an EGD. an EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology testing.

You asked the Plan to pay for the testing services. You say that this testing can prevent dangerous medication interactions. The Plan denied your request. The Plan says a panel constitutes a single procedural service.

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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pathology testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the urgent care services.

You asked the Plan to waive the copay for the services provided. You say that you were told you don't owe anything. The Plan denied your request. The Plan says the claim 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 $25 copay for urgently needed services in an urgent care center.

You have been asked to pay a $25 copay for the services provided. The services fall 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 copay for the urgent care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a firm mattress for the enrollee.

You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your request. The Plan says this does not serve a medical purpose.

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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a firm mattress for the enrollee.