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

We decided that the Plan does not have to waive the copayment for IV infusion therapy (96365) and a Privigen injection (J1459) provided on September 4, 2019.You asked the Plan to waive the copayment for IV infusion therapy and an injection. You say that you have never had to pay anything but a copay for your injection. You say you don't understand why you are being billed a coinsurance.The Plan denied your request. The Plan says Medicare Part B prescription drugs have a 19% coinsurance.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 19% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 19% coinsurance for IV infusion therapy and an injection. These servicesfall within the Medicare Part B prescription drugs benefit category(The allowable amount of $1,989.61 x 19% = $378.03). 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 IV infusion therapy (96365) and a Privigen injection (J1459) provided on September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital care provided from March 1, 2019 to March 5, 2019.You asked the Plan to pay for the inpatient hospital care. You say that this should be paid as it was an emergency admission.The Plan denied your request. The Plan says that a claim for services must be filed within 6 months of the date of service. This claim was not filed until July 31, 2019 which was not timely. Therefore, this claim cannot be paid.The Plan must follow Medicare rules. Medicare rules say that claims are timely when they are submitted within one year of the date of service. In this case, the Plan is applying an incorrect timely filing deadline of six months. In fact, the claim was also filed within this six month time frame and well within the correct one year time frame.Therefore, we decided that the Plan has to pay for the inpatient hospital care provided from March 1, 2019 to March 5, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have waive the coinsurance fora prostatectomy (52601, 85025, 36415, and C1758) provided from July 3, 2019 to July 9, 2019.You asked the Plan waive the coinsurance for a prostatectomy. You say that this should have been processed with an inpatient copayment.The Plan denied your request. The Plan says this claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for outpatient surgery services. You have been asked to pay a $804.11 ($4020.54 allowed amount x 20% coinsurance = $804.11) for a prostatectomy. A prostatectomy falls within the outpatient surgery 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 waive the coinsurance for a prostatectomy (52601, 85025, 36415, and C1758) provided from July 3, 2019 to July 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation services provided on April 22, 2019.
You asked the Plan to pay for the transportation services. You say that you would like reconsideration as the transportation services were medically necessary. The Plan denied your request. The Plan says ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment is considered part of the inpatient admission and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that 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. Records indicate the member was admitted inpatient on this date of service. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. Therefore, we decided that the Plan does not have to pay for transportation services provided on April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornurse practitioner services provided on July 11, 2019.You asked the Plan to pay forthe nurse practitioner services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.Medicare rules say that plans can require enrollees to get care fromnetwork 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 servicesat 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 fornurse practitioner services provided on July11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services provided on June 25, 2019.You asked the Plan to pay forthe physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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.Therequested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 forphysician's services provided on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 13, 2019 through June 17, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you should only be liable for $375 of you copayment.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 hospital care provided from June 13, 2019 through June 17, 2019. Therefore, you are asked to pay a $375 copayment per day for days 1 through 4 and a $0 copayment for additional days over 4. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fo rinpatient hospital care provided from June 13, 2019 through June 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99152, CPT 99153) provided on June 26, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older". The CPT Code Manual definition of code 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)".We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT codes 99152 and 99153 is not supported by the records provided. Our coding reviewer found that the record does not contain evidence that a trained, independent observer was present for the duration of the moderate sedation.We looked at this coder'sreview, the file, and Medicare rules. 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 for the services (CPT 99152, CPT 99153) provided on June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation did not include an itemized billing/shipping invoice.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 21, 2019 to May 31, 2019 by out of network provider.You asked the Plan to pay for these services. You say that the provider stated they would bill Medicare directly.The Plan denied your request. The Plan says the services were rendered by a non-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 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 April 21, 2019 to May 31, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on May 27, 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 testing is not covered.The Plan must follow Medicare rules. The rules say that the use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services.The file shows that the laboratory services at issue were ordered via telehealth. Medicare does not allow for these services to be ordered via telehealth.Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on May 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 24, 2019 by out of network provide.You asked the Plan to pay for physical therapy. You say that the physical therapy that was provided was provided by participating providers. You say that you would like this reprocessed for payment.The Plan denied your request. The Plan says the provider in question is out-of-network with the enrollee's plan. The Plan says that the referring provider is also out-of-network.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 December 24, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided.
You asked the Plan to pay for the panoramic x-ray. You say that you told the provider that you have limited coverage and could not afford a bunch of services or x-rays. You also say that because the office knew your situation, they should be responsible for paying for the x-rays. The Plan denied your request. The Plan says the panoramic x-ray is not a covered benefit under your plan. The Plan also says that the provider gave you a 50% discount for the non-covered panoramic x-ray.
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. The record shows that the provider gave you a 50% discount for the panoramic x-ray even though this is not covered by the Plan. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided.
Your complaint about the provider not paying for your x-ray 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that an ambulance was called because your blood sugar was extremely low. The paramedics arrived and treated you. You say that after treatment there was no need for transportation to the hospital and you declined transportation. You say that the Plan does not explicitly say that you must be transported for the ambulance services to be covered.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. Theambulance company did not provide transport services on July 9, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus vaccination provided on June 3, 2019.You asked the Plan to pay for the tetanus vaccination. You say that you would like reconsideration as you believed the shots would be covered benefits. The Plan denied your request. The Plan says coverage for a tetanus vaccination is covered under Medicare Part B if it is related to an accidental puncture wound or injury.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccination. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccination. Therefore, we decided that the Plan does not have to pay for a tetanus vaccination provided on June 3, 2019. Benefits for the tetanus vaccination. may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee by the provider on March 7, 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 payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules say that post-operative visits are included in the global surgical package. The provider submitted a claim for procedure code 99222 (initial hospital care). This claim was submitted in relation to a previous surgical procedure. Payment is included in the global surgical package for the original surgical procedure. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee by the provider  on March 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by your doctor on July 2, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a 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 $15 copayment for each specialist visit. You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided by your doctor on July 2, 2019.
We note your complaint that you are unhappy with the service you received from the provider. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the copayments for ultrasound and eye exam. You say that this was a pre-operative appointment and not a routine check-up. The Plan says that the copayment amounts you are being charged are correct.
We decided that the Plan has to waive the copayment for an eye ultrasound provided by your doctor on August 26, 2019.
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 copayment for ultrasound provided at a physician's office. The Plan has applied the $75 X-Ray copayment to this test, however this test is an ultrasound and therefore the X-Ray copayment does not apply to this charge.
The Plan says that you must pay the allowed amount of $60.31, which is less than $75 copayment for ultrasound. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for ultrasound. Therefore, we decided that the Plan has to waive the copayment for ultrasound.
We also decided that the Plan does not have to waive the copayment for an eye exam provided by your doctor on August 26, 2019.
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 copayment for a routine or diagnostic eye exam. Therefore, we decided that the Plan does not have to waive the copayments for eye exam.
Therefore, we decided that the Plan has to reduce your total cost-sharing obligation for this claim from $80.31 to $20 copayment.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee from February 19, 2019 to April 30, 2019.
You asked the Plan to pay for the medical services. 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 must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the physician  has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee from February 19, 2019 to April 30, 2019.