Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reducethe cost share forthe diagnostic mammogram. We decided that the Plan does not have to waive the cost share forthe biopsy. 
You asked the Plan to waive the cost share forthe diagnostic mammogramand the biopsy. You say that the biopsy was performed as a part of a follow up to a mammogram. You say you were under the impression that the mammogram and all related procedures were covered.The Plan says that you have been charged the correct cost sharing amount.We decided that the Planhas to reducethe cost share forthe diagnostic mammogram. The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the diagnostic mammogram does not apply to the deductible. Therefore, only thecoinsurance amount should apply to the diagnostic mammogram.The Plan says that you must pay $40.15 for the diagnostic mammogram. Based on the plan contract, however, you cannot be asked to pay more than an $8.03 for the diagnostic mammogram. ($40.15 x 20% = $8.03). Therefore, we decided that the Plan has to reduce the cost share for the diagnostic mammogram from $40.15 to $8.03. We also decided that the Plandoes not have to waive the cost share forthe biopsy.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 have a$1,000 deductible that applies towards the biopsy. Therefore, we decided that the Plan does not have to waive the cost share forthe biopsy
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on October 21, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the bill should be paid. The Plan denied your request. The Plan says the copayment 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 $20 copayment for lab services at an in-network freestanding laboratory. You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall 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 laboratory services provided on October 21, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to you on October 1, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this provider is not enrollee in the Medicare program.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 or supplier is enrolled in the Medicare program. 
We looked at the file and Medicare rules.The provider you received the services from is a Licensed Professional Counselor. This type of provider is no eligible to enroll in the Medicare program. Payment cannot be made for services rendered by a provider who is not enrolled in the Medicare Program.Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services provided to you on October 1, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve outpatient physical therapy services.
You asked the Plan to pre-approve physical therapy services. You say that without adequate movement, the enrollee's gastrointestinal motility will be compromised. The Plan denied your request. The Plan says that the enrollee's treatment is repetitive and not skilled in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy services. Our physician reviewer found that physical therapy is considered specific and effective for treating impairments of mobility due to comorbid medical conditions. The enrollee had previously been able to transfer using an EZ stand and now requires a Hoyer lift. Skilled therapy is needed in order to improve his ability to transfer. Without the skilled therapy services being requested, he will likely remain at a dependent level of function, placing him at risk for deterioration in his condition including due to skin breakdown and shearing forces when being transferred. For these reasons the skilled therapy services being requested are medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have been met. Therefore, we decided that the Plan has to pre-approve outpatient physical therapy services.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit provided on March 12, 2018.
You asked the Plan to pay for emergency room visit. You say that this claim was originally submitted within the timely filing period. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
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 emergency room visit was not filed until August 15, 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 an emergency room visit provided on March 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit, ophthalmic imaging and refraction provided on December 5, 2019.
You asked the Plan to waive the cost share for the office visit, ophthalmic imaging and refraction. You say that you were informed the provider is in-network. The Plan denied your request. The Plan says the cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,000, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Out-of-network office visits and diagnostic imaging are not excluded from the deductible. Your contract with the plan says that you must pay 25% coinsurance for one routine vision exam and up to two refractions annually from an out-of-network provider. The item or service you asked the Plan to waive the cost share for falls within the "Vision care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to the office visit and ophthalmic imaging. This cost sharing is a contractual obligation that had not been met at the time the office visit and ophthalmic imaging were received on December 5, 2019. Therefore, $204.44 has been applied to the deductible.
Since the refraction does not apply to the deductible, you have also been asked to pay $4.95, which is 25% of the allowed amount. The allowed amount is $19.79 (25% x $19.79 = $4.95). 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 cost share for the office visit, ophthalmic imaging and refraction provided on December 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on November 15, 2019.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that the copayment 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 paya $200 copayment for ground and air ambulances. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the ground and air ambulances 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 forthe ambulance transport provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on October 2, 2019.
You asked the Plan to pay for the genetic testing. 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 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 genetic 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 genetic testing provided on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 230 additional routine transports.
You asked the Plan to pre-approve these services. You say that your health is in jeopardy. The Plan denied your request. The Plan says you have exhausted the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 230 additional routine transports.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the physical therapy evaluation. We decided that the Plan does not have to waive the cost for the physical therapy evaluation.
You asked the Plan to waive the cost for the physical therapy evaluation. You say that you were not aware this was an outpatient situation. You say that you were not informed a charge would be incurred. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the cost for the physical therapy evaluation.
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 does not list a deductible that you must meet before the Plan will pay their share for your covered services. Therefore, we decided that the Plan has to reduce the cost from a $90.10 deductible amount to a $35 copayment.
We also decided that the Plan does not have to waive the cost for the physical therapy evaluation.
Your contract with the Plan clearly says that you must pay a $35 copayment for Medicare covered physical therapy services. Therefore, we decided that the Plan does not have to waive the cost for the physical therapy evaluation.
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 pay for the assistant surgeon services rendered to the enrollee on August 10, 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 the services are not covered. The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 15274 and 15273. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered to the enrollee on August 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 15, 2019 through October 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the notes provided show that prior to admission hours after arriving, her vitals, baseline oxygen supplementation, and general status was stable without uncontrolled or undiagnosed symptoms at that point. Additional time via observation status would have been sufficient based on this presentation. There was no expectation that the hospital stay would last at least two midnights, based on the provided documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 15, 2019 through October 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for astigmatism correcting function intraocular lens received on July 23, 2019 and August 14, 2019. You asked the Plan to pay for the lens. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit. The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for astigmatism correcting function intraocular lens received on July 23, 2019 and August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from August 22, 2019 to October 11, 2019.
You asked the Plan to waive the copayments for the wound care. You say that the wound care is outpatient only and non-surgical. You say your EOC does not stipulate a 'room charge' for outpatient clinical care. 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 for surgery services at an in-network outpatient hospital. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $250 copayment for wound care in an outpatient hospital.
You have been asked to pay a $150.15 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 that wound care is considered a surgical procedure.
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 wound care provided from August 22, 2019 to October 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on November 25, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that this should be paid because it was an emergency service you needed. The Plan denied your request. The Plan says that you are required to pay the copay.
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 copay for ambulance services. You have been asked to pay a $225 copay for the ambulance transport. The ambulance transport 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 copay for the ambulance transport provided on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on December 11, 2019.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were informed that dental was covered when you enrolled with this plan. The Plan denied your request. The Plan says these services are not covered under the Plan.
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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an OON provider on December 9, 2019.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the Premium dental rider promised a $0 cost for these services received by both in-network and out-of-network providers. You also say that in the literature it did not say that there were any caveats. The Plan denied your request. The Plan says the total member liability amount was applied correctly.
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, when using an out-of-network dentist, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an OON provider on December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480.
You asked the Plan to pay for the drug testing. 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. We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the laboratory test results were not submitted; therefore, the codes billed cannot be verified. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0480.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly services coded 99190 provided on November 11, 2019.
You asked the Plan to pay for the assembly 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 separately payable.
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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, these services were provided during inpatient hospitalization. Payment for this service would be included in the Part-A DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly services coded 99190 provided on November 11, 2019.