Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital care from January 10, 2020 through January 13, 2020.You asked the Plan to waive the coinsurance for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC 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). Review of the file show that you received inpatient hospital care from January 10, 2020 through January 13, 2020. You are asked to pay 15% coinsurance for the inpatient hospital care. 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 inpatient hospital care from January 10, 2020 through January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings of four or more teeth per quadrant and periodontal scaling and root planing of one to three teeth per quadrant provided on January 23, 2020 and January 31, 2020.
You asked the Plan to pay for the scalings and planings. You say that you feel that you are entitled to reimbursement for the cleaning charges. The Plan denied your request. The Plan says these services are not covered by Medicare.
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 two periodontal scalings and root planings of four or more teeth per quadrant and periodontal scaling and root planing of one to three teeth per quadrant provided on January 23, 2020 and January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 6, 2019 through March 15, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should be responsible for one (1) admission. The Plan denied your request. The Plan says these were two admissions and should be charged for both.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You were admitted to an in-network provider on February 27, 2019 for shoulder replacement surgery. You developed complications and had to be transferred to the intensive care unit (ICU), you were then stabilized and were ready for transfer for inpatient rehabilitation on March 6, 2019. These are two (2) separate hospitalizations. The treatment was indeed for the same condition; however, the first admission was for the surgery and the second was for rehabilitation. Therefore, you are asked to pay a $300 copayment per day for days 1-5 per admission. Your EOC states, enrollees must pay a $300 copayment per day for days 1-5 for in-network inpatient hospital care. Cost-sharing (copay and coinsurance) applies on the date of admission each time you are admitted or transferred to a specific facility type, including Inpatient Rehabilitation facilities, Inpatient Acute Care facilities, Inpatient Long Term Acute Care hospitals and Inpatient Psychiatric facilities. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care from March 6, 2019 through March 15, 2019 provided by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) provided on January 6, 2020 from a non-participating provider.You asked the Plan to pay for the lens. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the claim should be submitted to your supplemental vision plan.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. Review of the file shows that you purchased the lens on January 6, 2020 from an out-of-network provider. You are responsible for submitting a supplemental vision plan out-of-network claim form with itemized receipt when seeing a non-supplement. Please ask your provider to submit the claim to your supplemental vision plan.Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) provided on January 6, 2020 from a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on February 14, 2020.You asked the Plan to waive the deductible for an office visit. You say that you disagree with the out-of-network charges because you were referred to the doctor.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 $750 deductible for out-of-network physician/practitioner services, including doctor's office visits. The record shows that you had an office visit on February14, 2020 with an out-of-network provider. Therefore, you are responsible to pay the deductible amount of $203.40. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on February 14, 2020.Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (K0553) provided to the enrollee on October 13, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure Coding System (HCPCS) K0553 KX CG remains not supported. According to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. There were no claims submitted for an evaluation and management service. Review of claims history for this member, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. Of note, the patient resides in one state, and the ordering physician is located in another state. Therefore, the billed service cannot be verified. It is noted multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (K0553) provided to the enrollee on October 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on December 30, 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 88323 is not separately payable.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 88323 and 88342. Code 88323 is a column II code with a modifier indicator of 1 when billed with column I code 88342. Code 88323 was not billed with an appropriate modifier to allow for separate payment.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 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure),We find that CPT code 88341is not supported in the medical record. Specifically, there is no documentation that immunohistochemistry or immunocytochemistry was performed. 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 forthe laboratory services rendered on December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 18, 2019.You asked the Plan topay for the physician's services. The Plan denied your request. The Plan says services provided by non-participating providers are not covered unless they are authorized by the Plan before the services are provided.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 inthis case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 physician's services provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the Orthovisc injection. We decided that the Plan does not have to waive the coinsurance for the Orthovisc injection.
You asked the Plan to waive the coinsurance for the Orthovisc injection. You say that you weren't informed you would have a copayment. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to reduce the coinsurance for the Orthovisc injection.
The allowed amount for the injection is $295.69. (20% x $295.69 = $59.14). The plan says that you must pay $60.10 for the injection. Based on the Plan contract, however, you cannot be asked to pay more than $59.14. Therefore, we decided that the Plan has to reduce the coinsurance for the Orthovisc injection.
We also decided that the Plan does not have to waive the coinsurance for the Orthovisc injection.
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 the Orthovisc injection. Therefore, we decided that the Plan does not have to waive the coinsurance for the Orthovisc injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 3, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for specialist services. You say that these services were medically necessary. You
say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The
Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for
these services.
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 specialist services provided on January 3, 2020 by
an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 25, 2020 and March 17, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says you are required to obtain outpatient psychotherapy services from a network behavioral health 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 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 psychotherapy services provided on February 25, 2020 and March 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the endoscopy provided on February 5,
2020.
You asked the Plan to waive the cost share for the endoscopy. You submitted your bill for review. You say that
the deductible was never taken on the claim. The Plan denied your request. The Plan says the cost share applied
correctly.
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 your deductible is $1,000. This is the amount you have to pay out-of-pocket
before we will pay our share for your covered medical services. Until you have paid the deductible amount,
you must pay the full cost for most of your covered services. Your contract with the Plan also says that after
you pay your $1,000 deductible, you pay a $250 copayment for each in-network, Medicare-covered outpatient
surgery.
The item or service you asked the Plan to waive the cost share for falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies
to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the
endoscopy was received on February 5, 2020. Therefore, $847.17 has been applied to meet your deductible.
Since your $1,000 deductible has been met, you have also been asked to pay $67.36, which is less than the
standard $250 copayment for the endoscopy. The total amount you owe is $914.53 ($847.17 + $67.36 =
$914.53). This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the cost share for the endoscopy provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheters provided on January 17, 2020.You asked the Plan to waive the coinsurance for the catheters. You say that you cannot afford to pay this.The Plan denied your request. The Plan says that the claim processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered prosthetic devices and supplies. You have been asked to pay a 20% coinsurance for the catheters. The catheters fall within the Medicare-covered prosthetic devices 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 coinsurance for the catheters provided on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 21, 2019.You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the services are not supported by the records.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you do not take walk-ins. You say that you report your findings back to the doctor. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 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 lab work provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on December 31, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on December 31, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 20, 2019. You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 psychotherapy services provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on February 24, 2020.You asked the Plan to waive the deductible 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 $0 or $198 deductible. If you are eligible for Medicare cost-sharing assistance under Medicaid, you have no deductible. You had an office visit on February 24, 2020. The record shows that you are no longer eligible for Medicaid assistance. Therefore, you are responsible to pay the $85 deductible. You have been asked to pay a $0 or $198 deductible 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 deductible for an office visit provided on February 24, 2020.