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

We decided that the Plan does not have to waive the cost share for the Part B drugs and the clinic visits.

You asked the Plan to waive the cost share for the Part B drugs and the clinic visits. You say that the Plan should be paying more for these claims. 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 in-network Medicare-covered Part B drug and a $15 copayment for in-network primary care physician for each outpatient clinic visit.

You have been asked to pay a total of $1,072.18 for the Part B drugs and the clinic visits. The Part B drugs fall under the "Medicare Part B prescription drugs" benefit category. The clinic visits fall within the "Outpatient hospital services" benefit category. See provided chart.

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 Part B drugs and the clinic visits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department service provided on June 13, 2020.

You asked the Plan to pay for the emergency department service of high severity level (99284). You say that the Plan should pay this claim at the high severity level. The Plan denied your request. The Plan says the procedure code and reimbursement was changed because it more accurately describes the services rendered.

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 99284 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. 

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 the emergency department service of high severity level. Our reviewer says that the documentation submitted does not meet the criteria. Our physician reviewer found the emergency department visit report supports an expanded problem focused history (brief HPI) and detailed exam. The report does not support a detailed history and exam, and moderate decision making, therefore it would inappropriate to report CPT 99284. 

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 emergency department service of high severity level have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department service 99284 provided on June 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visit.

You asked the Plan to waive the copayment for the physical therapy visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network Medicare-covered therapy visit.

You have been asked to pay a $35 copayment for the physical therapy visit. The physical therapy visit falls within the "Outpatient rehabilitation 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 physical therapy visit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for myocardial perfusion imaging (78452), echocardiography (93306), a stress test (93015), and supplies (A9500).

You asked the Plan to waive the cost-sharing for myocardial perfusion imaging, echocardiography, a stress test, and supplies. You say that you were told you would have no cost-share for these services. The Plan denied your request. The Plan says these services 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 Medicare-covered medical supplies, a $30 copayment for non-radiological diagnostic services, and a $125 copayment for each radiological diagnostic service.

You have been asked to pay a $125 copayment each for myocardial perfusion imaging and echocardiography, which are radiological diagnostic services, a $30 copayment for a stress test, and a $48.68 coinsurance for supplies ($243.40 allowed amount x 20% = $48.68). 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-sharing for myocardial perfusion imaging (78452), echocardiography (93306), a stress test (93015), and supplies (A9500).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided by a participating provider on August 20, 2020.

You asked the Plan to waive the copayment for an urgent care visit. You say that you believe this copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied to the services that were provided.

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 urgently needed services. 

You have been asked to pay a $35 copayment for an urgent care visit. The correct copayment has been applied to the services that were provided. An urgent care visit falls within the urgently needed 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 an urgent care visit provided by a participating provider on August 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture repair (D5611) provided on October 9, 2020.

You asked the Plan to pay for the dental service. You say that it is not your fault that your dentures keep breaking. You say that they were still cracked when you got them back the first time. You also say that the material is very thin. The Plan denied your request. The Plan says denture repairs are covered once per calendar year. The Plan also says that the frequency limit has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of once per year has been exceeded. The record shows that the Plan paid for a denture repair that you received on May 15, 2020. Therefore, we decided that the Plan does not have to pay for the denture repair (D5611) provided on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services.

You asked the Plan to pay for office services. You say that you were told that this provider was in-network. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan is the secondary payer for you and cannot process these claims until the primary insurance carrier's payment information for this claim is received.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has attempted to obtain your primary insurance carrier's explanation of benefits for these claims. As the secondary insurer, the Plan cannot be held responsible for office services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for office services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the hospital should pay because they were unable to provide the services you required. The Plan denied your request. The Plan says the ambulance services are a covered benefit, and the correct cost share amount was 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 $225 copayment for ambulance services. 

You have been asked to pay a $225 copayment for the ambulance transportation. This 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 services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided from March 2, 2020, through March 30, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services are not payable as they were rendered by a non-certified Medicare provider.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has indicated that the services are not payable as they were rendered by a non-certified Medicare provider. However, a review of the database shows that your organization is Medicare-certified and is associated with CCN# 222305. The Plan referenced CCN# 222321 appears to belong to a different facility. We have not received documentation from the Plan to explain this discrepancy. Therefore, we decided that the Plan has to pay for the medical services provided from March 2, 2020, through March 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on September 23, 2020.

You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges because you did not have any symptoms and did not have any tissue removed so you should not owe a copayment. 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 $250 copayment for outpatient surgery, including services provided at ambulatory surgical centers. 

The medical records show that you received a colonoscopy on September 23, 2020, due to fecal changes. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $250 copayment. 

You have been asked to pay a $250 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including 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 a colonoscopy provided on September 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital outpatient clinic visit (G0463) debridement of a wound (11042) provided September 15, 2020 to September 22, 2020.

You asked the Plan to waive the copayment for the outpatient visits. You say that per phone call you are faxing 2 bills for reconsideration on how they were processed by the Plan. The Plan denied your request. The Plan says the claims were processed and the correct copayment was 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 $350 copayment for surgery and other services provided at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges for Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. 

You have been asked to pay ($671.54 $116.67 + 116.67 + $321.54) for the outpatient visits. For each date, the allowed amounts were lower than the copayment amount. Therefore, you are responsible for the lesser amounts. The outpatient visit 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 hospital outpatient clinic visit (G0463) debridement of a wound (11042) provided September 15, 2020 to September 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional speech therapy visits for the enrollee.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of demonstration of potential to improve.

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 the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and the documentation does not indicate that the patient's functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee 's current condition or to prevent or slow further deterioration.

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional speech therapy visits for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that you were instructed to go to the ER for an ultrasound. You say if you had been able to get an ultrasound appointment then your radiology copayment would apply. 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 $90 copayment for each emergency room visit.

You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. The record shows you were seen at the emergency room. 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 ER visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation provided from June 9, 2020, to June 18, 2020.

You asked the Plan to waive the copayment for inpatient rehabilitation. You say that you are fully covered for days 1-20 and 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 $230 copayment for days 1-7 for inpatient hospital care. 

The record shows that you received inpatient rehabilitation, not skilled nursing facility care, from June 9, 2020, to June 18, 2020. Therefore, you are responsible to pay a $230 copayment for days 1-7 (June 9, 2020, to June 15, 2020). $230 (copayment) x 7 (inpatient days) = $1,610. 

You have been asked to pay the total copayment amount of $1,610 for inpatient rehabilitation. Inpatient rehabilitation 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 inpatient rehabilitation provided from June 9, 2020, to June 18, 2020.