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

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 24, 2019.You asked the Plan to waive the copayment for the ER visit. You say that you were informed to return if there was extra bleeding or pain. You say that you weren't given proper information.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 $85 for each visit to an emergency room.You have been asked to pay an $85 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 provided on January 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99239 provided on April 4, 2019.You asked the Plan to pay for CPT code 99239. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.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 99239 is Hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, procedure code 99239 is a time based code. In order to bill CPT 99239, the documentation must note that more than thirty minutes was spent providing services to the enrollee on the day of discharge. The progress note for April 4, 2019 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of CPT 99239. Based on this information, we decided that Medicare rules for coverage of CPT code 99239 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 99239 provided on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 00790 provided on February 17, 2020.You asked the Plan to pay for CPT code 00790. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. CPT code 00790-QZ is not supported. The medical records provided include documentation that indicates the anesthesia service 00790 was performed with medical direction/medical supervision, therefore, the use of a QZ modifier indicating services delivered without medical direction by a physician is inappropriate. The modifier choices that are appropriate when there is medical direction/medical supervision are QY, QX, and AD. Based on this information, we decided that Medicare rules for coverage of CPT code 00790 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 00790 provided on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 16, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you rely on the skilled nursing facility to obtained prior authorization. You say that you provide these services in good faith. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no indication in the records provided that services were ordered by a participating provider.
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 skilled nursing services provided on December19, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four periodontal scalings and root planings provided on January 14, 2020.
You asked the Plan to pay for the scalings and planings. You say that the dental secretary told you everything would be covered. You also say that you do not have the money to pay for these services. 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 periodontal scalings and root planings provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on August 19, 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 procedure code 99152 is 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 by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness or physiological status. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 14, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were informed there was no charge. 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 $40 copayment for specialist services. You have been asked to pay a $40 copayment for the office visit. The 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 the office visit provided on November 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy provided on January 7, 2020.
You asked the Plan to waive the copayment for the biopsy. 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 a surgical procedure on the date of service at issue in this appeal. The Plan says that 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 $350 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a biopsy, a surgical procedure on January 7, 2020. You have been asked to pay a $350 copayment for the biopsy. The biopsy 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 waive the copayment for the biopsy provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from November 26, 2019 to December 8, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. 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 $395 copayment for each day for days 1 to 4 for in-network Medicare-covered hospital care. You have been asked to pay a $395 copayment for each day for days 1 to 4 of the inpatient hospital stay. ($395 x 4 = $1,580). The inpatient hospital stay 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 the inpatient hospital stay provided from November 26, 2019 to December 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the requested viscosupplement agent is subject to step therapy.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. The provided medical records do not document that the enrollee has satisfied these requirements. There is no documentation that the preferred agents are contraindicated or would not be tolerated.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 11, 2019, and September 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on September 11, 2019, and September 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient hospital services provided on November 19, 2019.
You asked the Plan to waive the deductible for outpatient hospital services. You say that you should not be responsible for the charges because you received preventative services. 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. Your contract with the Plan says that there is a $300 deductible for outpatient hospital services, non-surgical. You received outpatient hospital services on November 19, 2019. The record shows that you had paid $0 toward the $300 deductible. Therefore, you are responsible to pay the allowed mount of $133.69. Please note that you were not charged for preventative services. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient hospital services, non-surgical. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient hospital services, non-surgical. This cost sharing is a contractual obligation that had not been met at the time outpatient hospital services was received on November 19, 2019. Therefore, we decided that the Plan does not have to waive the deductible for outpatient hospital services provided on November 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays provided on February 11, 2020.
You asked the Plan to waive the copayment for the x-rays. You say that you did not see a specialist or a doctor. You say that you shouldn't have a copayment. 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 $50 copayment for basic radiological services at an in-network specialist's office. You have been asked to pay a $50 copayment for the x-rays. The x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the provider is a radiologist, which is considered a specialist. 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 x-rays provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
November 21, 2019.
You asked the Plan to pay for the intraoral x-rays. You say that x-rays were taken that you did not want. The
Plan denied your request. The Plan says the copayment was applied appropriately.
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 contract clearly says that you are
responsible for a $40 copayment for complete series of intraoral x-rays (D0210). The record shows that you
gave consent to the x-rays by initialing below that policy, and you were charged the correct $40 copayment for
this service. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays
(D0210) provided on November 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on September 5, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration as these services were reasonable and necessary. The Plan denied your request. The Plan says diagnosis code R6532 requires the diagnosis code for the first underlying disease and should never be listed as the primary diagnosis for a procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Specifically, diagnosis code R65.2 is a "code first" code. This means that R65.2 should not be listed as the primary diagnosis in this case. The appropriate code for the underlying systemic infection should be coded first. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the routine foot care provided on January 14, 2020.
You asked the Plan to waive the deductible for the routine foot care. You say that you have not had to pay any cost share previously for routine foot care. You say you believe routine foot care should be covered at 100% without any member liability. 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 out-of-network routine foot care. The routine foot care you asked the Plan to waive the deductible for falls within the "Podiatry services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 out-of-network deductible for out-of-network routine foot care. This cost sharing is a contractual obligation that had not been met at the time the routine foot care was received on January 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the routine foot care provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on August 26, 2019, and December 16, 2019.
You asked the Plan to pay for the services. You say that the services were paid for your husband from the same provider. The Plan denied your request. The Plan says this provider has opted out of Medicare.
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 in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that 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 the services provided to you on August 26, 2019, and December 16, 2019.