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

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428,
A0425) received November 20, 2020.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you were not given
a choice regarding the ambulance transportation and you do not think you should owe a copayment. The Plan
denied your request. The Plan says the correct cost share applied to the claim.

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 $200
copayment for Ambulance Services.

You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation 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 waive the copayment for the ambulance transportation (A0428, A0425) received November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00790 provided on July 24, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 00790 is anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified.

We find that CPT code 00790 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00790 provided on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic tests provided by an out-of-network provider on February 11, 2021.

You asked the Plan to pay for the diagnostic tests. You say that the doctor ordered a pulmonary function test and the enrollee presented to the office for further evaluation. You say that the test result and office notes support the medical necessity and the service should be approved for payment. The Plan denied your request. The Plan says prior authorization was required but 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 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 diagnostic tests provided by an out-of-network provider on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray rendered on March 2, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for basic radiological services at an outpatient hospital.

Review of the file shows that you had a knee x-ray on March 2, 2021. Per the contract with the Plan, there is a $100 copayment for basic radiological services at an outpatient hospital. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $88.20. Given that the allowed amount was less than the $100 copayment, you have been asked to pay $88.20 for these services.

Therefore, we decided that the Plan does not have to waive the copayment for the x-ray rendered on March 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy (PT) visits.

You asked the Plan to pre-approve the home health PT visits. You say that home health PT is medically necessary. The Plan denied your request. The Plan says home health PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health PT visits. Our reviewer says that home health PT is not medically necessary or reasonable. Our physician reviewer found that based on the documentation provided, it is my opinion that the health Plan's denial should be upheld. You do not have documented skilled therapy needs. You have not made measurable progress with home health PT and a home exercise program. As such, ongoing home health PT is not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health PT visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided February 1, 2021, to February 24, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you are appealing the non-payment of your additional 4 days stay at the rehab facility. Due to the winter sub and subsequent power outages, you could not be released on your 20th day because you were on oxygen. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.

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 $0 per day for SNF days 1-20 and $184 per day for SNF days 21-100.

You have been asked to pay $736.00 ($184 x 4 days) for the SNF services. The SNF services falls within the skilled nursing facility (SNF) 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 skilled nursing facility (SNF) services provided February 1, 2021, to February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on December 11, 2020.

You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic ultrasound, diagnostic (76512) received February 8, 2021.

You asked the Plan to waive the copayment for the ophthalmic ultrasound. You say that did not know you would have to pay two copays. You would not have gone if you knew you would have to pay two copays. The Plan denied your request. The Plan says if x-ray services are performed in the provider's office during an office visit, the appropriate office visit copayment and x-ray copayment will apply.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $35 copayment for the ophthalmic ultrasound. The ophthalmic ultrasound 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 the ophthalmic ultrasound, diagnostic (76512) received February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 9, 2020, to July 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that these services were self-referred.

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 on April 9, 2020, to July 14, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on January 28, 2021.

You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you would like the Plan to reconsider removing the copayment charge. The Plan denied your request. The Plan says you were charged this copayment 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 $325 copayment for Outpatient surgery. 

You have been asked to pay $325 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient surgery benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on January 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four home health physical therapy sessions (G0151).

You asked the Plan to pre-approve four home health physical therapy sessions. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 four home health physical therapy sessions. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee is compliant with exercises, bike and walking around the house with cane and spouse present. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of four home health physical therapy sessions have not been met. Specifically, the enrollee does not need a therapist to safely and effectively perform the requested services, or to deliver a program to maintain the patient's condition or prevent further deterioration. This means the requested service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve four home health physical therapy sessions (G0151).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test provided on May 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the drug test. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 drug test provided on May 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 had network providers available who could have provided 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 services provided by an out-of-network provider on April 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are not enough studies to show that the use of this device will help in the enrollee's care.

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 pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laparoscopy provided on January 5, 2021.
You asked the Plan to pay for the laparoscopy (43775). You say that the provider rendered quality care to the enrollee in good faith and payment should be granted for this claim. The Plan denied your request. The Plan says a Licensed Surgical Assistant is not a practitioner covered by Medicare.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the laparoscopy provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on February 24, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that you cannot afford this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for physician/practitioner services/specialist. You have been asked to pay a $25 copayment for a specialist office visit. A specialist office visit falls within the physician/practitioner services/specialist 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 specialist office visit provided by a participating provider on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81551) provided on July 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not authorized.
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 laboratory services (81551) provided on July 26, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0428) received January 3, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that it was not your choice to be transported by ambulance. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 for Ambulance Services.

You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 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 waive the copayment for the ambulance transportation (A0425, A0428) received January 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the new patient office or other outpatient visit (99204) received February 25, 2021.

You asked the Plan to pay an additional amount for the outpatient visit. You say that you went for a regular eye exam. During the exam the doctor found that there was an issue with your cataracts and are being billed for your cataract condition. The Plan denied your request. The Plan says if you receive services that address a medical condition during an annual routine eye exam, you pay $40 instead of $15.

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 Vision Care.

You have been asked to pay a $40 copayment for the outpatient visit. This outpatient visit falls within the Vision Care, (Medicare-covered outpatient visit for services to diagnose and/or treat a diseases or condition of the eye) 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 an additional amount for the new patient office or other outpatient visit (99204) received February 25, 2021.