Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cholangiopancreatography procedure provided on October 23, 2019.
You asked the Plan to waive the coinsurance for the cholangiopancreatography procedure. You say that you should not be responsible for 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 20% coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $555.99 which is 20% of the allowed amount for the cholangiopancreatography procedure. The allowed amount is $2,779.95. ($2,779.95 x 20% = $555.99). The cholangiopancreatography procedure falls within the "Outpatient Surgery and Other Medical 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 coinsurance for the cholangiopancreatography procedure provided on October 23, 2019.
Your complaint about the doctor's error is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin biopsy provided on October 3, 2019.You asked the Plan to waive the copayment for the skin biopsy. You say that you would like the plan to cover the cost of the service without any member liability. 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 $260 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $260 copayment for the skin biopsy.You have been asked to pay a $173.28 copayment for the skin biopsy. The skin biopsy falls within the "Outpatient Surgery and Other Medical 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 the skin biopsy provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the initial observation care provided on August 21, 2019.You asked the Plan to waive the coinsurance for the initial observation care. You say that you were in the hospital on this date of service but you do not feel responsible for the doctor's bill. 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 20% coinsurance for each surgical or observation room service you get an in-network outpatient hospital. You have been asked to pay $26.97 which is 20% of the allowed amount for the initial observation care. The allowed amount is $134.83. ($134.83 x 20% = $26.97). The initial observation care falls within the "Outpatient hospital 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 coinsurance for the initial observation care provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered to enrollee on November 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 procedure code 99190 is not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered to enrollee on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the member's primary care physician did not refer theseservices. 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 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 foran office visit provided on November 6, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter items purchased February 4, 2019 to December 5, 2019.
You asked the Plan to pay for the over-the-counter items. You say that these items are listed as reimbursable on the Flex Benefit Form and Covered Items list and you feel that these items should be covered. The Plan denied your request. The Plan says the Flex Benefit is not included as a part of the plan's benefit package.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the over-the-counter items is an OTC item. Therefore, we decided that the Plan does not have to pay for over the counter items purchased February 4, 2019 to December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 15, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee received these services in the facility during an inpatient hospitalization and payment for these services would be included in the Part A-DRG payment to the facility. The Plan states payment for these services is the responsibility of the facility.
The Plan must follow Medicare rules. 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. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy infusion provided on December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chemotherapy infusion. You say that these services are medically necessary. The Plan denied your request. The Plan says prior authorization is required for these services. The Plan says that prior authorization was 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 chemotherapy infusion provided on December 3, 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 surgical services rendered on December 20, 2018.
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 procedure code 63090 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 63090 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment. We find that CPT code 63090 is not supported in the medical record. Specifically, the operative report did not include documentation of a partial or complete vertebral corpectomy. 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 surgical services rendered to on December 20, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis and hip joint adjustable flexion provided on September 24, 2019.
You asked the Plan to pay for the hip orthosis (L1686) and hip joint adjustable flexion (L2624). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The 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 the telehealth 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 items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the hip orthosis and hip joint adjustable flexion provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that you need a power wheelchair. The Plan denied your request. The Plan says there is no information provided that your home has adequate space to use a power wheelchair.
The Plan follows Medicare rules. Medicare rules say that there must be a written report of a home assessment. The file does not contain a home assessment. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out of network services with the provider. You say that the medical records provided support the medical necessity of the services being requested. The Plan denied your request. The Plan says once the enrollee signs a Medicare approved clinical trial consent form, Original Medicare is responsible for covered clinical trial services furnished to beneficiaries enrollees in managed care plans.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the out of network services with the provider as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee needs the electronic upgrades to control the features for increased independence. The Plan denied your request. The Plan says The electronic upgrades cannot be covered as it is not medically necessary to control the three approved power options through the joystick (drive interface).
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Documentation shows that the enrollee has normal range of motion and 3/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care and discharge day management (99232, 99233, 99239) provided from November 23, 2018 to November 27, 2018.You asked the Plan to pay for hospital care and discharge day management. You say that this was filed timely.The Plan denied your request. The Plan says this was filed more than a year after the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for hospital care and discharge day management was not filed until December 3, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for hospital care and discharge day management (99232, 99233, 99239) provided from November 23, 2018 to November 27, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine you received on November 21, 2019.
You asked the Plan to pay for the shingles vaccine. You say that you were told the vaccine was covered. The Plan denied your request. The Plan says the vaccine is not covered under your medical benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine you received on November 21, 2019.
Benefits for the shingles vaccine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 1, 2019 to October 8, 2019.You asked the Plan to pay for the SNF services. You say that you are a valid provider and have been since 1994. You have been working with various representatives to get this situation resolved.The Plan denied your request. The Plan says the plan cannot pay a provider who is not eligible to participate in Medicare The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider and supplier enroll in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October 1, 2019 to October 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided by out of network (OON) provider, NP on October 16, 2019.You asked the Plan to pay forthese services. You say that you are requesting reconsideration of the Plan's denial as the nursing facility isresponsible to obtain prior authorization for their patients, which should cover medical treatments by the provider.The Plandenied your request. The Plan says the services were provided by an out of network provider, 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 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 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 services.Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided by the out of network (OON) provider on October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on July 19, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided on November 27, 2018 through November 29, 2018.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because the stay was over a 13 months ago. 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 $225 copayment per day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from November 27, 2018 to November 29, 2018. Therefore, you are responsible to pay a $225 copayment for days 1-2 (November 27, 2018 to November 28, 2018). $225 (copayment) x 2 (inpatient days) = $550. You have been asked to pay the total copayment amount of $550 for an inpatient hospital stay. An inpatient hospital 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 provided on November 27, 2018 through November 29, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a home blood pressure monitor.
You asked the Plan to provide a home blood pressure monitor. You say that the enrollee had a medication change and was told to monitor blood pressure at home. The Plan denied your request. The Plan says the enrollee is not receiving home dialysis.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to provide a home blood pressure monitor.