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

We decided that the Plan does not have to waive the copayment for the x-ray provided on August 13, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that the orthopedist requested the x-ray and now you have two $45 charges. You say that you don't feel you owe $45 for the x-ray. 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 $45 copayment per provider, per date of service for routine radiology (x-ray, radiology, diagnostic services, ultrasounds). You have been asked to pay a $45 copayment for the x-ray. The x-ray 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 the x-ray provided on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on October 12, 2018.You asked the Plan to waive the copayment forthe office visit. You say that you are not back to normal after three surgeries.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 $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 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 forthe office visit provided on October 12, 2018.Your complaint about the unfortunate results of the surgeriesis 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 March 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the physician provided medically necessary services in good faith. The Plan denied your request. The Plan says there are in-network providers available.
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 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 on March 3, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 83880, CPT 87633) provided on April 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not covered.
The Plan follows Medicare rules. Medicare rules say that BNP testing is covered for the above indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested BNP testing was not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 58-year-old female with diagnosed respiratory failure, COVID-19, acute kidney failure, pneumonia, and anemia. CXR showed new patchy infiltrates, but no signs of heart failure. A request was made for natriuretic peptide. This enrollee does not meet the LCD criteria as the initial workup was not suggestive of heart failure and the appropriate treatment had been initiated already. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 83880 have not been met. Medicare rules also say that LCA A57340 provides a list of non-covered CPT codes. We looked at the file and Medicare rules. Per A57340, CPT code 87633 is non-covered. Payment cannot be made for a non-covered service. Based on this information, we decided that Medicare rules for coverage of CPT 87633 have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 83880, CPT 87633) provided on April 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 4, 2020, by an OON provider.
You asked the Plan to pay for a telehealth provider visit. You say that this service was necessary due to COVID-19 restrictions. The Plan denied your request. The Plan says rules for payment have 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 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 August 4, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the pelvis billed with CPT code 72190 for date of service July 31, 2020.
You asked the Plan to pay for the x-ray of the pelvis. You say that the claim denied in error. The Plan denied your request. The Plan says the code in dispute is a column 2 procedure to the column 1 procedure which already paid.
Plan must follow Medicare rules. The rules say that when a NCCI edit exists between two codes, generally only the Column 1 code is payable, unless the modifier indicator for the code is 1 and a clinically appropriate modifier is used to bypass the edit. CPT code 72190 is a Column 2 code in relation to code 73502. CPT code 72109 was not billed with a clinically appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for an x-ray of the pelvis billed with CPT code 72190 for date of service July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on July 17, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you want to why your leg pain is not being taken care of.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 andcoinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for physician specialist services.You have been asked to pay a $45 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 forthe office visit provided on July 17, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 15, 2020, to June 13, 2020.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 15, 2020, to June 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on March 16, 2020.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on March 16, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing provided on February 3, 2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the cost is included inthe cost of the primary procedure.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.The file shows that train of four testing was provided as part of intraoperative neuromonitoring services. it is inappropriate to separately report these services based on standard medical and surgical principles.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing provided on February 3, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided from July 8, 2020, to July 15, 2020.You asked the Plan to pay forinpatient care. You say that the enrollee's hospice status was revoked before admission.The Plan denied your request. The Plan says the denial of payment for this inpatient stay is correct, because Original Medicare is responsible for coverage of benefits until the end of the month in which hospice status is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on July 8, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided from July 8, 2020, to July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services provided on July 12, 2020.You asked the Plan to pay forthe testing services. You say that there is not another lab that offers the same type of testing.The Plan denied your request. The Plan says there are not five or more gene tests that meet the standards for testing.The Plan must follow Medicare rules. Medicare rules say that testing services are only covered under certain medical indications. Welooked at the file and Medicare rules. The records provided do not show that the results of the tests will be used in the treatment of the enrollee. The documentation does not indicate why the additional testing was ordered. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe testing services provided on July 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 19, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that transportation services
were not provided. You say that this claim should not be paid. 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 $65
copayment for each separate Medicare-covered ambulance service.
You have been asked to pay a $65 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 on
August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on August 3, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you were told when you signed up with
the Plan that you would not owe a 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 $150
copayment for each radiological diagnostic service.
You have been asked to pay a $150 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 on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 22, 2020.You asked the Plan to waive the copayment forthe office visit. Yousay that Medicare is responsible for paying 80% and the Plan is responsible for 20%.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 Medicare-covered, in-network, physician specialist services. You have been asked to pay a $50 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 forthe office visit provided on September 22, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee.

You asked the Plan to pay for the orthosis. You say that this was medically necessary for the enrollee.The Plan denied your request. The Plan says that Medicare pays for a limited number of Part B services furnished by a physician or practitioner to an eligible beneficiary via a telecommunications system.

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 non covered visit are likewise non covered.Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power scooter rendered on July 3, 2020.
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 provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the power scooter rendered on July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 17, 2019, by an OON provider.You asked the Plan to pay fora domiciliary or rest home visit and chronic care management services. You say that services were rendered in good faith to the enrollee.The Plandenied your request. The Plan says rules for payment have 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 can provide the items/services at issuein 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 December 17, 2019, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from June 5, 2020, to July 19, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were notauthorized.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 forthe medical services provided to the enrollee by an out-of-network provider from June 5, 2020, to July 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mental health services rendered from April 21, 2020 to May 28, 2020.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 provider type is not covered.The Plan must follow Medicare rules. The rules say that a marriage family therapist is not eligible to participate in Medicare. We looked at the file and Medicare rules. The file shows that the provider is a licensed marriage family therapist. This provider type is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe mental health services rendered from April 21, 2020 to May 28, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit and therapeutic procedure provided on July 30, 2020.You asked the Plan to pay forchiropractic services. You say that this was needed due to weakness from shingles.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay foran office visit and therapeutic procedure provided on July 30, 2020.