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

We decided that the Plan does not have to pay for the services provided to the enrollee on July 5, 2019.You asked the Plan to pay for the services provided to the enrollee on July 5, 2019. You say that you made attempts to resolve the issues associated with this claim on July 29, 2019, October 3, 2019 and also via your letter which was received on December 30, 2019.The Plan denied your request. The Plan says there is confirmation that the claim was billed 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.The Plan states the records do not show a telephone call to the Plan's call center on July 29, 2019 and they have no record of receiving the form dated July 29, 2019, a copy of which you included with the letter. The Plan's records, do show a call on October 3, 2019 to the call center. At that time, you were advised of the correct address to submit additional information or requests for claim review. The information your submitted with your letter does show that you may have attempted to resubmit the claim and a request for claim review form but the address indicated on the claim form is incorrect. We have no record of receiving those documents.The referenced claim was originally denied because the HCPCS code or modifier billed is a non-covered HCPCS code or modifier per Medicare billing guidelines. After reviewing the claim, there is confirmation that the claim was billed incorrectly. For this reason, the denial is upheld. Please note, that you are still within the time frame for submitting claims for the date of service of July 5, 2019. Based on this information, we decided that Medicare rules for coverage of the services provided to the enrollee on July 5, 2019have not been met.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on July 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from November 28, 2019 through December 4, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The 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 (suchas copayments, deductibles and coinsurance). Review of the file shows that you were admitted on November 28, 2019 and discharged on December 4, 2019. You were asked to pay a $275 copayment per day from November 28, 2019 through December 3, 2019, days 1-6 of your inpatient hospital care. You were discharged on December 4, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $275 copayment per day required for days 1-6. This means that you have been asked to pay thecorrect amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care from November 28, 2019 through December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network vision services provided on October 15, 2019.
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network vision services provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe perfusionist services provided on November 12, 2019.You asked the Plan to pay forthe services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine for the enrollee's surgery.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility.The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. 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 forthe perfusionist services provided to n November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on November 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the drug screen was done so the doctor knows if there are drugs in the enrollee's system that may conflict with prescribed medication. The Plan denied your request. The Plan says non-emergent services by non-participating providers require 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 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on November 13, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea partial maxillary denture, cast metal framework with resin base (D5213).You asked the Plan to pre-approvethe dental service. You say that your provider requested a solid partial. You say that you foundout that your plan will only pay for the flexible partial. You say that none of the providers that you have talked to do the flexible partials anymore. You also say that you are hoping you will be allowed to get the solid partial because of this.The Plan denied your request. The Plan says the partial maxillary denture, cast metal framework with resin base, is not a covered 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 requested partial denture is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea partial maxillary denture, cast metal framework with resin base (D5213).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fortelehealth services provided to the enrollee on October 18, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the provider is appealing the denial of a claim for laboratory testing services ordered via telemedicine. A physician located in MD, ordered lab testing via telemedicine for the enrollee who was located in SC, a Medicare prohibited action.  Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounterThe Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that thetelehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fortelehealth services provided to the enrollee on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2750) for tooth #9.
You asked the Plan to pre-approve the crown. You say that the enrollee needs a crown with buildup on tooth #9.You also say that tooth #9 was treated 30 years ago, 10 years ago a re-treatment was performed and canal was calcified, and presently the enrollee is asymptomatic. The Plan denied your request. The Plan says that the completed root canal treatment does not meet clinically acceptable standards for root canal therapy. The Plan also says that the x-rays show that the filling in the tooth canal does not go all the way to the tip of the root.
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 the crown. Our reviewer says that the service meets criteria for coverage. Our physician reviewer found the rules of coverage for a root canal state that the root canal filling must be properly condensed/obturated and must be within 2mm of the radiological apex (unless there is a curvature or calcification that limits the ability to fill the canal to the radiological apex). Our reviewer found that the enrollee's record indicates that there was a calcification that prevented the filling to reach the apex. The enrollee has been asymptomatic for 10 years and there is no indication of periapical pathology radiographically. Our physician reviewer also found that the criteria for coverage for a crown for tooth #9 have been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2750) for tooth #9.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound care provided on November 19, 2019 and December 27, 2019.
You asked the Plan to reduce the copayments for the wound care. You say that you were told you would have a $250 copayment. You say you do not feel its fair to pay the higher 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 $325 copayment for outpatient hospital facility. You have been asked to pay a $325 copayment for the wound care on each date of service. The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by an outpatient hospital.
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 copayments for the wound care provided on November 19, 2019 and December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 26, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services from October 13, 2019 through November 6, 2019.You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received.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 inpatient mental health care from October 13, 2019 through November 6, 2019. You stepped down from inpatient treatment level to outpatient/partial hospitalization. You were under partial hospitalization until November6, 2019. The Plan processed and paid accordingly, applying the $225 inpatient mental health care copayment per day for days 1 through 6 (total of $ 1,350) and the $55 partial hospitalization copayment per day (total of $550). 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 services from October 13, 2019 through November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 13, 2019 to October 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for office visits. You say that you are appealing based on medical necessity.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 and 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 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 September 13, 2019 to October 29, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on October 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 11, 2019.
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says oral exams are covered once every 6 months. The Plan also says that the frequency limit has been exceeded.
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 and oral exams are a covered service, the frequency limit has been exceeded. The record shows that the Plan paid for the oral exam that you received on September 18, 2019. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on December 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the CT scans provided on October 15, 2019.
You asked the Plan to waive the copayments for the CT scans. You say that you assumed the CT scans would be covered because you have never been billed by this provider before. You say you cannot afford this amount. 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 $300 copayment for other outpatient diagnostic tests, including CT scans. You have been asked to pay a total of $196.00 for the CT scans. The CT scans fall within "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
October 15, 2019
Thoracic CT scan
$115.76
$300.00
$115.76
October 15, 2019
Maxillofacial CT scan
$80.24
$300.00
$80.24
Total
$196.00
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 CT scans provided on October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan provided on June 3, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that this should be considered preventative. 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 $125 copayment for CT scans. You have been asked to pay a $125 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 for a computed tomography (CT) scan provided on June 3, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on September 5, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says medical records were not received from the ordering provider.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 documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverageof the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on September 5, 2019
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for outpatient hospital services. We decided that the Plan does not have to reduce the cost-sharing charges for outpatient hospital services to the amount you requested. You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you met the MOOP amount for the year and disagree with the charges.The Plan says that the claims were processed correctly and you are being charged the correct amount.We decided that the Plan has to reduce the cost-sharing charges for outpatient hospital services from $1,550.88 to $1,270.15. The plan contract says that the combined MOOP amount for 2019 is $5,100.The record shows that you had paid $3,829.85 toward the $5,100 MOOP amount prior to receiving services. Therefore, we decided that the Plan has to reduce the cost-sharing charges for outpatient hospital services from $1,550.88 to $1,270.15. We also decided that the Plandoes not have to reduce the cost-sharing charges for outpatient hospital services to the amount you requested. 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 50% coinsurance for out-of-network outpatient hospital services.Therefore, we decided that you are responsible to pay $1,270.15, which is less than the 50% coinsurance amount. 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.