Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and x-ray (73502) provided on December 13, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit and x-ray. You say that you should be considered innetwork. The Plan denied your request. The Plan says these services were 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 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 office visit (99213) and x-ray (73502) provided on December 13, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the blood pressure monitor purchased over-the- counter on November 24, 2019. 
 
You asked the Plan to reimburse you for the blood pressure monitor. You say that you need the blood pressure monitor to monitor your blood pressure. The Plan denied your request. The Plan says blood pressure monitors are not covered by Medicare and you purchased yours through a non-participating over-the-counter provider. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Also, your over-the-counter benefit does not apply to a non-participating provider. Therefore, we decided that the Plan does not have to reimburse you for the blood pressure monitor purchased over-the-counter on November 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit November 30 to December 2, 2019. 
 
You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should have been waived. The Plan denied your request. The Plan says the correct copayment 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 $50 copayment for Emergency Care.  
 
You have been asked to pay a $50 copayment for the Emergency Room visit. The Emergency Room visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an Emergency Room Visit November 30 to December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient consultation services (CPT 99254) provided to the enrollee on August 15, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this service. 
 
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 99254 is "Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive 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 moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
We find that CPT code 99254 is not supported in the medical record. Specifically, this code has a status indicator of "I." This means that the code is not valid for Medicare purposes. 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 inpatient consultation services (CPT 99254) provided to the enrollee on August 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $225 copayment charged for ambulance transport on
January 19, 2020.
You asked the Plan to waive this copayment. You say that because you have insurance, you should not have
any large copayments and would like the Plan to waive the copayment. The Plan denied your request. The Plan
says this copayment was charged based on the services provided and your Plan contract agreement.
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 each one-way ambulance transport. 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 $225 copayment charged for
ambulance transport on January 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on September 25, 2018. 
 
You asked the Plan to pay for the eyeglasses. You say that you did file within the proper time frame but you did not receive any notification and forgot about it. You do not believe you received any eye glass benefits for the year 2018. The Plan denied your request. The Plan says the claim was received past the 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 the eyeglasses was not filed until December 30, 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 the eyeglasses purchased on September 25, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the renal dialysis provided from November 13, 2019 to December 31, 2019. 
 
You asked the Plan to waive the coinsurance for the renal dialysis. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you had renal dialysis on the dates of service at issue in this appeal. The Plan states the correct coinsurance has applied per your contract with the Plan. 
 
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 renal dialysis.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received renal dialysis from November 13, 2019 to December 31, 2019. You have been asked to pay a 20% coinsurance for each renal dialysis service, totaling $61 per visit. The renal dialysis falls within the Services to treat kidney disease benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the renal dialysis provided from November 13, 2019 to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four endosteal implants (D6010 x4) provided on December 5, 2019. 
 
You asked the Plan to pay for the endosteal implants. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
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 four endosteal implants (D6010 x4) provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 1, 2019, to June 3, 2019. 
 
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that the services could have been provided under observation. 
 
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 the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee's condition stabilized and improved with therapy and she was discharged home on June 3, 2019, when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 1, 2019, to June 3, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns provided by an out-of-network provider on December 6, 2019 and December 20, 2019. 
 
You asked the Plan to pay for the crowns. You say that before the work was done you faxed a tentative list from your transplant doctor showing that the services were medically necessary. The Plan denied your request. The Plan says your benefit had been exhausted. 
 
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 Plan offers a $7,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on October 18, 2019 and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the crowns provided by an out-of-network provider on December 6, 2019 and December 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating facility on August 13, 2019. 
 
You asked the Plan to waive the copayment for an MRI. You say that you were never told that you would owe this much. 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 $200 copayment for outpatient diagnostic tests/diagnostic radiology.  
 
You have been asked to pay a $200 copayment for an MRI. Since an MRI was provided, the correct copayment has been applied. An MRI falls within the outpatient diagnostic tests/diagnostic radiology 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 MRI provided by a participating provider on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided from October 23, 2019 through November 27, 2019. 
 
You asked the Plan to waive the copayment for the wound debridement. You say that it was a short procedure. You say that the charges are excessive and a hardship. The Plan denied your request. The Plan says the copayments 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 $200 for each in-network, Medicare-covered outpatient hospital facility visit. 
 
You have been asked to pay a $200 copayment for each wound debridement visit. The total amount you owe is $1,000 ($200/visit x 2 visits = $1,000). Wound debridement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The wound debridement is considered a surgical procedure that was provided by the hospital. 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 wound debridement provided from October 23, 2019 through November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 7, 2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.   
 
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 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 a domiciliary, rest home visit provided on October 7, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for finger x-rays (73140) provided on December 13, 2019. 
 
You asked the Plan to pay for the finger x-rays. You say that you would like reconsideration because you are an invisible provider who performs the read for the images that are taken at the facility. The Plan denied your request. The Plan says that services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code. 
 
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 code 73140 is supported in the record. Specifically, the claim at issue was billed by a different provider than that which was processed and paid. Column I/II edits do not apply when the services are billed by separate providers. Based on this information, we decided that Medicare rules for coverage of the finger x-rays have been met. Therefore, we decided that the Plan has to pay for finger x-rays (73140) provided on December 13, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided from August 9, 2019 to October 4, 2019.
You asked the Plan to pay for services from providers who are not Medicare eligible. You say that this physician has been very beneficial in your treatment and you believe the Plan should cover these services. The Plan denied your request. The Plan says the Plan contract is clear that enrollees must providers who are eligible to accept Medicare payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided from August 9, 2019 to October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the medical services provided to the enrollee on January 9, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that the cost of services have been paid in full, plus an overpayment. The Plan denied your request. The Plan says the cost sharing applied was correct based on the 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copay for each Medicare-covered visit with a PCP.  
 
The enrollee has been asked to pay a $10 copay for the services provided. The services fall within the physician services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. The plan paid the provider according to their agreement with the provider. Therefore, we decided that the Plan does not have to waive the copay for the medical services provided to the enrollee on January 9, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for deluxe frames (V2020) and bifocal lenses (V2200 and V2203) purchased on July 17, 2019. 
 
You asked the Plan to waive the copayment for the vision services. You say that you were told the plan would pay for the exam and you needed to pay the copay as well as the frames and the plan would pay the rest. The Plan denied your request. The Plan says the correct cost share 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 if the eyewear you purchase costs more than $100 you pay the difference.  
 
You have been asked to pay $29. The plan has also verified that the $29 balance was paid at the time the eyeglasses were picked up. The vision services fall within the Vision 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 deluxe frames (V2020) and bifocal lenses (V2200 and V2203) purchased on July 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on December 25, 2019. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received emergency room services on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan. 
 
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 $50 copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows you received emergency care on December 25, 2019. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the Emergency 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 emergency room visit provided on December 25, 2019.