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

We decided that the Plan does not have to pay for home infusion therapy services provided from July 26, 2019 to August 2, 2019.You asked the Plan to pay for the services. You say that this should bepaid for.The Plan denied your request. The Plan says this is not valid for Medicare purposes.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 definition of HCPCS code S9328 is "Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem."We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates 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 home infusion therapy services provided from July 26, 2019 to August 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for enteral formula (B4152) provided from January 4, 2019 to May 2, 2019.You asked the Plan to waive the copayment for enteral formula. You say that this should fall under Part B.The Plan denied your request. The Plan says the appropriate 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).The contract with the Plan clearly says that enrollees must pay a $20 copayment for Durable Medical Equipment and Related Supplies. The enrollee has been asked to pay a $10.50 copayment for enteral formula. Enteral formula falls within the Durable Medical Equipment and Related Supplies 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. Therefore, we decided that the Plan does not have to waive the copayment forenteral formula (B4152) provided from January 4, 2019 to May 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on July 2, 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 the documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on July 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on July 11, 2019 and billed under code G0483.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare coverage criteria for this testing are not met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay forlab services provided to the enrollee on July 11, 2019 and billed under code G0483.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided from August 21, 2019 to August 28, 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 code is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of HCPCS code S9328 is "Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem."We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates 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 home infusion therapy services provided from August 21, 2019 to August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory services on August 6, 2019.You asked the Plan to waive the deductible for the laboratory services. You say that the lab services are related to your annual physical visit and should be fully covered by the plan with no deductible.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. Your contract with the Plan says that there is a $400 deductible that applies towards in-network Medicare-covered lab services. The laboratory services you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category in-network Medicare-covered lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible that applies towards in-network Medicare-covered lab services. See chart below.Date of ServiceServiceAllowed AmountDeductibleMember LiabilityAugust 6, 2019Complete blood count$7.20$400$7.20August 6, 2019Comprehensive blood test$9.78$400$9.78August 6, 2019Thyroid stimulating hormone test$15.56$400$15.56Total$32.54
This cost sharing is a contractual obligation that had not been met at the time the laboratory services was received on August 6, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthelaboratory services provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 7, 2019 by an out of network provider. You asked the Plan to pay forthese services. You say that you disagree with the denial.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 forthe medical services provided on May 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe bronchoscopy provided on August 29, 2019.You asked the Plan to waive the copayment forthe bronchoscopy. You say that the service was not done correctly. You say that you should get a refund.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 $400 copayment per date of service for outpatient surgery at an outpatient hospital facility.You have been asked to pay a $400 copayment for the bronchoscopy. The bronchoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the bronchoscopy was performed. 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 bronchoscopy provided on August 29, 2019.Your complaint about the delay in treatment 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 2, 2019 to May 8, 2019 by out of network provider.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 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 May 2, 2019 to May 8, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for water aerobics provided on July 8, 2019.You asked the Plan to reimburse you for the water aerobics. The Plan denied your request. The Plan says the fitness benefit is provided.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only when provided by Renew Active.The Plan's rules for coverage of gym benefits have not been met because the provider is not a participating fitness provider with the Plan. Therefore, we decided that the Plan does not have to reimburse you forwater aerobics provided on July 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forimaging services providedto the enrollee on July 8, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says they have verified the enrollee has an effective "plan" for date of service July 08, 2019 andis listed as the primary insurance carrier. Per the above Medicare regulations, the plan is upholding its decision to deny payment as it is the provider'sresponsibility to bill the Primary Group Health Plan or any liability insurance before submitting the claim to the enrollee's plan. 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. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the primary payer and given instruction on claim submission. As the secondary insurer, the Plan cannot be held responsible for this service until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forimaging services provided to the enrollee on July 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided on June 14, 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 the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore the billed codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided on June 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services (97530 and 97535) provided on August 28, 2019.
You asked the Plan to pay for occupational therapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
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 pay for occupational therapy services. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the patient's condition. The patient has had extensive therapy and has reached a plateau. The patient's functional level no longer requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to be performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program. The patient has had extensive therapy and at this point the specialized skill, knowledge and judgment of a qualified therapist are not
required to establish, design and/or deliver a program to maintain the patient'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 occupational therapy services have not been met. Therefore, we decided that the Plan does not have to pay for occupational therapy services (97530 and 97535) provided on August 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the outpatient surgery services you received on July 22, 2019.You asked the Plan to adjust the cost share. You say that you were quoted an amount of $280.90.The Plan denied your request. The Plan says you are responsible for the 20% 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 20% coinsurance for each Medicare-covered outpatient hospital facility visit for outpatient surgery services. Review of the file shows that you received outpatient surgery services on July 22, 2019. The services were allowed at a total of $3,865.47. You have been asked to pay a 20% coinsurance for the services, totaling $773.07. The services falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to adjust the cost share for the outpatient surgery services you received on July 22, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient hospital clinic visits provided by the "medical center"  from January 24, 2019 to July 2, 2019.You asked the Plan to waive the copayments for clinic visits. You say that you have already paid a copayment for your doctor visits, and you believe these charges are beyond what you should have to pay.The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.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 each outpatient hospital clinic visit. There were 5 clinic visits, resulting in a total copayment obligation of $100.You have been asked to pay $20 copayment for each clinic visit. Clinic visits fall within the Outpatient Hospital 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 copayments foroutpatient hospital clinic visits provided by the "medical center" from January 24, 2019 to July 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided.
You asked the Plan to waive the copayment for the ambulance transport. You submitted your bill for review. You say that this is a hardship. 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 $200 copayment for each trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to 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 the ambulance transport provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen system and battery pack.
You asked the Plan to pre-approve these items. You say that you cannot travel with the tank which you use when you are at home. The Plan denied your request. The Plan says that the reasonable useful lifetime (RUL) for oxygen equipment is 5 years.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen system and battery pack.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided on September 11, 2019 and September 18, 2019.
You asked the Plan to waive the copayments for the office visits. You say that you paid two copayments to the doctor that gave you an incorrect diagnosis. You say that you received a second opinion and were informed you did not need surgery. 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 a $50 copayment per visit to a specialist. Covered services include consultation, diagnosis and treatment by a specialist. You have been asked to pay a $50 copayment for each office visit. The total amount you owe is $100 ($50/visit x 2 visits = $100). The office visits fall 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 copayments for the office visits provided on September 11, 2019 and September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe bathtub to shower conversion provided by the provider from April 25, 2019 to May 20, 2019.You asked the Plan to reimburse you forthe bathtub to shower conversion. You say that because of your knee condition you needed a step-in shower tobe safe.The Plan denied your request. The Plan says renovating your bathtub into a shower does not serve a primarily medical purpose and is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment tobe covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to reimburse you forthe bathtub to shower conversion provided from April 25, 2019 to May 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing foroutpatient hospital services received on June 27, 2019 and July 22, 2019.You asked the Plan to waive the cost-sharing forthe services. You say that the copayment was lower before.The Plan denied your request. The Plan says the claim was processed appropriately according to your benefits and the services rendered.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 hospitalservices. You have been asked to pay $442.26 for the services. The services fall within the outpatient hospital services benefit category. The copayment for one of the visits was $250, and the other visit was $192.26, as the allowed amount for that was under $250. 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 foroutpatient hospital services received on June 27, 2019 and July 22, 2019