Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forpost and crown services provided by "the doctor" on July 1, 2019.You asked the Plan to pay forthe dental services. You say that the plan has paid nothing for these services, nor did it pay anything for an earlier root canal ordered by the provider, yet you have had more than $6,000 in out of pocket costs.The Plan denied your request. The Plan saysthe claim was 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 50% coinsurance. There is annual maximum benefit of $1000 for Dental services. You say that the plan has not paid for your dental services. The provider billed $5,680. The plan allowed $1,926 and paid $890. There is annual maximum benefit of $1000 and 50%coinsurance which was applied."the doctor" is not an in-network provider and is able to bill for the difference between the billed amount and the plan's allowed amount for the dental services. The services falls within the Dental 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 pay forpost and crown services provided by "the doctor" on July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CPAP device rentals provided on August 15, 2019 and September 15, 2019.You asked the Plan to waive the coinsurance forthe CPAP device rentals. You say that you have never had to pay a rental fee for the last ten years of using a CPAP device. 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 durable medical equipment from an in-network durable medical equipment provider. You have been asked to pay $6.74 which is 20% of the allowed amount for each the CPAP device rentals. ($6.74 + $6.74 = $13.48). The allowed amount is $33.71. ($33.71 x 20% = $13.48). The CPAP device rentals fall within the "Durable medical equipment (DME) and related supplies" 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 forthe CPAP device rentalsprovided on August 15, 2019 and September 15, 2019.Our decision is only about the August 15, 2019 and September 15, 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic walking boot (L4360) provided September 13, 2019.You asked the Plan to pay for pneumatic walking boot. You say that the enrollee was provided a walking boot on 9/03/19 and then had surgery. During his post-op visit he was provided a different boot because the first boot no longer fitting correctly.The Plan denied your request. The Plan says this is a duplicate of a charge considered on a previous claim.The Plan must follow Medicare rules. Medicare rules say that says that the reasonable useful lifetime for DME and prosthetics, such as braces, is five years. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pneumatic walking boot have not been met.Therefore, we decided that the Plan does not have to pay forpneumatic walking boot (L4360) provided September 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient psychiatric stay provided by  Medical Center from May 19, 2019 to June 3, 2019.
You asked the Plan to pay for inpatient psychiatric stay. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this inpatient hospital admission was not medically necessary and care could have been provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric stay. Our reviewer says that this inpatient hospital stay does not meet the Medicare criteria for coverage. Our physician reviewer found based upon review of the records provided, it was not expected that this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others and was not showing any behavioral issues. The enrollee was found to be calm and cooperative, yet confused. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care.
The health plan's denial of inpatient psychiatric services is appropriate. The enrollee did not require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. The services were not reasonably expected to improve the enrollee's condition or for the purposes of diagnosis. The documentation submitted does not include an individualized treatment plan. The services were supervised and evaluated by a physician. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient psychiatric stay provided by  Medical Center from May 19, 2019 to June 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of glucagon hydrochloride (J1610) provided by the provider on July 11, 2019.You asked the Plan to waive the coinsurance for an injection. You say that this is all part of the same procedure which was the magnetic resonance imaging (MRI) that was done on July 11, 2019. You say that the injection was to calm down your gut.The Plan denied your request. The Plan says Medicare Part B prescription drugs that aren't self-administered by the patient have a 20% coinsurance.The injection you received is a separate service from the MRI. 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 Part B prescription drugs. You have been asked to pay a 20% coinsurance for an injection. This service falls within the Medicare Part B prescription drugs benefit category. The allowable Medicare amount of $200.26 x 20% = $40.05. 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 an injection of glucagon hydrochloride (J1610) provided on July 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for routine transportation services provided to the enrollee on September 11, 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 a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or 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. We find that CPT code A0425 is not supported in the medical record. Specifically, this code needs to be billed with a primary diagnosis code, not a secondary diagnosis code. 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 routine transportation services provided to the enrollee on September 11, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had fallen in the night and an ambulance was called. The responders came and treated you and assisted you up. You say that your wife believed you were okay and declined transportation to the hospital. You state you should not be liable for the full cost of the ambulance response. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 9, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you disagree with the ambulance response charge. You say that you were not aware that you would be charged for being treated and not going anywhere. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 24, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by your doctor on July 23, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for a primary care provider visit. The medical records show that you had an office visit provided by your doctor on July 23, 2019. Therefore, you are responsible to pay the $5 copayment. You have been asked to pay a $5 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided by your doctor on July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on June 12, 2019.You asked the Plan to waive the copayment for lab tests. You say that you cannot afford this copayment.The Plan denied your request. The Plan says the copayment amount you are being charged is 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 lab tests. You have been asked to pay the allowed amount of $19.66, which is less than the $20 copayment for lab tests. Lab tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory testing provided on June 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe inpatient hospital care you received from February 21, 2019 to February 25, 2019.You asked the Plan to waive the cost share forthe inpatient hospital care. The Plan denied your request. The Plan says the claim was processed based on your plan 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). Your contract with the Plan clearly says that you must pay $225 copay per day for days 1 to 8 for inpatient hospital care. The file shows that you received emergency and observation care from February 21-22, 2019. You were not charged the emergency room cost share for these service because you were admitted to the hospital within 24 hours. You received 2 days of inpatient hospital care from February 23-25, 2019. You were charged a $225 copay for each day, totaling $450. Theinpatient services fall within the inpatient hospital care benefit category. This means that you have been asked to paythe 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 forthe inpatient hospital care you received from February 21, 2019 to February 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe advanced care planning rendered to the enrollee by the provider on July 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99497 is not separately payable.The Plan must follow Medicare rules. The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 99497 (advanced care planning) and 99220 (initial observation care). Code 99497 is a column II code with a modifier indicator of 1 when billed with column I code 99220. Code 99497 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe advanced care planning rendered on July 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on July 18, 2019.You asked the Plan to pay for the comprehensive periodontal evaluation (D0180). You say that  The Plan denied your request. The Plan says you did not go out of network for this service. You say you are asking for a one-time courtesy for the periodontal evaluation to be paid.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 comprehensive periodontal evaluation (D0180) is not among those covered under this benefit, regardless if the service was provided in or out of network. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided on July 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora vascular study (93976) provided on August 6, 2019 by an out of network provider.You asked the Plan to pay forthe vascular study. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization, therefore coverage criteria has not been met.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 canprovide 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 fora vascular study (93976) provided on August 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 9, 2019.You asked the Plan to pay for lab tests. You say that this testing is covered by Medicare and should be paid by the Plan.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the enrollee was enrolled in a hospice program on this date of service and therefore the Plan is not responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for laboratory testing provided on August 9, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay formedical nutrition therapy (97803) provided by "the provider" July 29, 2019.You asked the Plan to pay formedical nutrition therapy services. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says as a non-covered service this is not a benefit when ordered by either a contracted or non-contracted provider.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that "the beneficiary" suffers from renal disease or diabetes.Therefore, we decided that the Plan does not have to pay formedical nutrition therapy (97803) provided by "the provider" July 29, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay these services until they are addressed by Original Medicare. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says while code 81311 was eligible for payment, this entire claim should be submitted to Original Medicare for review due to the enrollee's hospice election at the time of service.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to address this claim for payment until it has been reviewed by Original Medicare.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on June 13, 2019.You asked the Plan to waive the copayment for an MRI. You say that you should only owe a $180 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 advanced imaging services provided in an outpatient hospital facility. You have been asked to pay a $250 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 June 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inhalation of nitrous oxide/analgesia provided on September 3, 2019.You asked the Plan to pay forthe inhalation of nitrous oxide/analgesia. You say that this service seems it would be much less costly than the novocaine injections it would have taken in order to numb the multiple teeth you were having worked on. You also say that you were never advised by the provider that this was not a covered service.The Plan denied your request. The Plan says this service is not covered under the terms of your benefit plan.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 forthe inhalation of nitrous oxide/analgesia provided on September 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from January 7, 2019 to January 16, 2019.You asked the Plan to pay forhome health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the documentation does not include a signed order from a healthcare provider for the home health care services rendered. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from January 7, 2019 to January 16, 2019.