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

We decided that the Plan does not have to waive the copayment fora specialist visit (99214) provided from July 19, 2019 through July 20, 2019.You asked the Plan to waive the copayment for a specialist visit. You say that you were in the hospital overnight having an operation on your left foot. You don't know the doctor in this claim. You say that he never came to your room or made contact with you. You want the Plan to pay the doctor with no responsibility to you.The Plan denied your request. The Plan says outpatient hospital services with a specialist have a $25 copayment.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for outpatient hospital services. You have been asked to pay a $25 copayment for a specialist visit. This service falls within the outpatient hospital services benefit category. The record shows that the physician performed the history and physical on July 19, 2019 and the discharge summary on July 20, 2019.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 specialist visit (99214) provided from July 19, 2019 through July 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on July 17, 2019.You asked the Plan to waive the copayment fora CT scan. You say that 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 planmust 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 $180 copayment for advanced imaging services provided in a freestanding radiological facility. You have been asked to pay the allowed amount of $100.96, which is less than the $180 copayment for a CT scan. A CT scan 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 fora CT scan provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 2, 2019 by out of network provider.
You asked the Plan to pay for practitioner services. You say that the facility requested that your practitioner treat the enrollee, therefore medical necessity is established. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan, the referring facility is also out-of-network with the Plan, and the Plan did not authorize service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 2, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2019 by out of network provider. You asked the Plan to pay for aboratory test. You say that this test is covered by Medicare.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 ordering physician 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 fo rthe medical services provided on July 8, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortherapeutic procedures (97116-59) provided from March 13, 2019 to March 30, 2019.You asked the Plan to pay forthe therapeutic procedures. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.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 Manualdefinition of code 97116 is a therapeutic procedure.We asked our coding 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 the therapeutic procedures. Our coding reviewer says that the services are not supported by the medical records provided. Our MAXIMUS coding reviewer found CPT code 97116 with modifier 59 is not supported by the medical records. According to NCCI edits, CPT code 97116 is a column II code with CPT code 97530, which was also reported on the same dates of service. The documentation does not contain sufficient detail to support that 97116 is a separately identifiable procedure from the services reported with CPT code 97530. The use of modifier 59 is not supported.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS emergency ambulance services provided.You asked the Plan to pay for the ambulance services. You say that you received a statement showing that the plan paid $182.38 and you were obligated to pay $300. You have now received invoices from the plan showing a balance of $1,412.52.The Plan denied your request. The Plan says this claim was processed as in-network but since the provider is out of network they can balance bill.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 $1,412.52. The health plan contract says you have a $300 copay for Medicare covered ground transportation. for Ambulance services. You have been asked to pay $1,412.52. The health plan contract says you have a $300 copay for the ambulance services. The emergency ambulance services falls within the Ambulance 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 pay for the ALS emergency ambulance services provided by Grady Health System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diabetic eye exam provided by on October 9, 2019.You asked the Plan to waive the copayment for the diabetic eye exam. You say that this service should be covered because you have never had to pay for this before and it was medically necessary because you have diabetes. 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 $40 copayment for an annual diabetic retinopathy exam. You have been asked to pay a $40 copayment for the diabetic eye exam. The diabetic eye exam falls within the "Vision care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diabetic eye exam on October 9, 2019.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home dialysis rendered from July 1, 2019 to August 30, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says that a corrected claim is needed.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 Plan states that a corrected claim is needed; however, the Plan has not provided further explanation as to what needs to be corrected on the claim or any Medicare rules to support that the original claim was not billed correctly. There is no documentation in the case file to support that the claims were not billed correctly. Therefore, we decided that the Plan has to pay for the home dialysis rendered from July 1, 2019 to August 30, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided by the doctor.
You asked the Plan to pay for office visits. You say that you were told you could have unlimited chiropractic manipulation and are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered when performed by a chiropractor. The Plan also says that they have reprocessed and paid for the chiropractic manipulative treatments, therefore this denial is only for the office visit charges.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for office visits provided by the doctor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from March 19, 2019 to March 20, 2019.You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you were seen in the emergency room and did not need to stay overnight. 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 $250 copayment per admission for hospital inpatient services. You have been asked to pay a $250 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows that you were considered an inpatient.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 stay provided from March 19, 2019 to March 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the cervical cancer screening rendered to you by the doctor.
You asked the Plan to pay for these services. You say that the yearly visit should be covered. The Plan denied your request. The Plan says that Medicare does not pay for this line as a result of Medically Unlikely Edit.
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 Plan states that the services are not covered due to a Medically Unlikely Edit (MUE); however, further explanation is not provided. There is no documentation of the MUE(s) that were billed, or documentation to support that the claim could not be paid as billed. Therefore, we decided that the Plan has to pay for the cervical cancer screening rendered to you by the doctor.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99233) provided.
You asked the Plan to pay for subsequent hospital care. You say that this should be paid. The Plan denied your request. The Plan says this service is included in the global surgical package of 32653.
The Plan must follow Medicare rules. Medicare rules say that post-operative services routinely performed by the surgeon or by members of the same group with the same specialty are included in the global surgical package. We looked at the file and Medicare rules. The record shows that the enrollee received a thoracoscopy (32653) from the provider. The global period for this service is 90 days. This service is therefor included in the global surgery package. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99233) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hand finger orthosis (L3913) provided from July 10, 2019 through August 13, 2019.You asked the Plan to waive the coinsurance for the orthosis. You say that you had surgery on your hand November 13, 2018. You state you feel as though the doctor did not suggest any alternatives to surgery for your pain. You state your hand is still in pain and the provider failed at your 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 a hand finger orthosis (L3913) provided from July 10, 2019 through August 13, 2019. You are asked to pay 20% coinsurance for the orthosis. 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 hand finger orthosis (L3913) provided from July 10, 2019 through August 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chronic care management services (99490) rendered by an out of network provider, on August 31, 2019.You asked the Plan to pay forthese services. You say that the living facility requested your organization's nurse practitioners and/orphysicians be called in to see the patient as an attending provider in an outpatient capacity; therefore, you feel medical necessity has been pre-established.The Plan denied your request. The Plan says the services were provided out of network without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of areaurgent care and pre-approved care.The providers in this case are not network providerswith 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 forthe chronic care management services (99490) rendered by the out of network providers on August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora phlebomotyprocedure provided on July 22, 2019.You asked the Plan to waive the copayment for specialist service. You say that you do not see a doctor when you have this procedure, and the provider's billing department questions why you were charged this 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 $35 copayment for in-network specialist service. You have been asked to pay $35 copayment for specialist service. Specialist service 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 inthe Plan.Therefore, we decided that the Plan does not have to waive the copayment fora phlebomoty procedure provided on July 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora general health panel provided to the enrollee.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says insufficient medical records were submitted to support this service was not a general screening.The Plan must follow Medicare rules. Medicare does not cover screening lab services. Insufficient medical records were provided to determine the medical necessity of this service. Therefore, we decided that the Plan does not have to pay for a general health panel provided to the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on September 16, 2019.You asked the Plan to waive the copayment for an MRI. You say that the provider was not an outpatient hospital facility.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 $250 copayment for advanced imaging services provided in an outpatient hospital facility. You received an MRI on September 16, 2019. The provider is considered an outpatient hospital facility. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for an MRI. An MRI 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 an MRI provided on September 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction by neurolytic agent provided on August 27, 2019.You asked the Plan to waive the copayment for the destruction by neurolytic agent. You say that you have never been charged a copayment before.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 an $80 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the destruction by neurolytic agent provided on August 27, 2019. The destruction by neurolytic agentis considered an outpatient surgical procedure. Therefore, you are responsible to pay the $80 copayment. You have been asked to pay an $80 copayment for the destruction by neurolytic agent. The destruction by neurolytic agent 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 fo rthe destruction by neurolytic agent provided on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received at an outpatient hospital facility on August 16, 2019.You asked the Plan to waive the copayment. 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 $20 copayment for lab services at an outpatient hospital. Review of the file shows that you received lab services at an outpatient hospital on August 16, 2019. You have been asked to pay a $20 copayment for the services. The services fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the lab services you received at an outpatient hospital facility on August 16, 2019.