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

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 3, 2019. You asked the Plan to waive the copayment for the colonoscopy. You say that you were under the impression the colonoscopy was preventive. You say you are requesting the services are covered in full. The Plan denied your request. The Plan says you have beencharged 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 mustpay a $325 copayment for outpatient hospital facility. You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient hospital services" benefit category. The record shows the colonoscopy was performed due to an iron deficiency diagnosis. Therefore, the colonoscopy was diagnostic in nature. 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 colonoscopy provided on September 3, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for critical care services (CPT 99291) provided to the enrollee on July 8, 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 that CPT 99291 is not inclusive to CPT 90935, and should not be bundled.
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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes." We asked our coding 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 reviewers says that the services at issue in this case were coded correctly. Our coding reviewer found the record does not show that the provider who reported 99291 also performed a service that would be bundled with 99291, according to Medicare rules. Coding rules do not require a modifier for CPT code 99291 in this case. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for critical care services (CPT 99291) provided to the enrollee on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forchronic care management services (99490) provided on June 14, 2019.You asked the Plan to waive the copayment for chronic care management services. You say that you don't need this service and you would like to be asked first before receiving services.The Plan denied your request. The Plan says physician services have a $10 copayment for services furnished at a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location.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 $10 copayment for physician services. You have been asked to pay a $10 copayment for chronic care management services. This service falls within the physician services benefit category. The record indicates that you were seen by a physician on the same date of service. 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 forchronic care management services (99490) provided on June 14, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing foroffice visits, cardiac catheterization, and diagnostic tests provided from January 3, 2019 to April 29, 2019.You asked the Plan to waive the cost-sharing forcardiology services and diagnostic tests. You say that these charges should all have been paid at the in-network rate.The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $45 copayment for in-network office visit, 50% coinsurance for out-of-network specialist services, and 50% coinsurance for out-of-network diagnostic tests. Please note that although the provider is out-of-network with the Plan, the office visit on date of service January 3, 2019 was processed at the in-network rate which results in a lower cost-sharing amount for you.Your total cost-sharing obligation is $1,378.31.You have been asked to pay $45 copayment for in-network office visit, 50% coinsurance for out-of-network specialist services, and 50% coinsurance for out-of-network diagnostic tests. Cardiology services and diagnostic tests fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit categories. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost-sharing for office visits, cardiac catheterization, and diagnostic tests provided from January 3, 2019 to April 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 5, 2019 through May 7, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the inpatient stay is not medically necessary and was only approved for observation.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 5, 2019 through May 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from March 15, 2019 through April 8, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee was released from the hospital too soon. The Plan denied your request. The Plan says the stay is a new admission and the enrollee is responsible for the cost-share.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 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 waive the copayment for inpatient hospital care. Our physician reviewer found the readmission was not a result from a premature discharge from the same hospital. We looked at this physician's review, the file, and Medicare rules. Therefore, the enrollee must pay a $310 copayment per day for the first 6 days for each Medicare-covered admission to a network hospital. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from March 15, 2019 through April 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI you had.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for each Medicare-covered advanced imaging service. Review of the file shows that you had an MRI. Per your contract with plan name, there is a $200 copayment for advanced imaging services. However, the Medicare allowed amount for these services was $197.52. Given that the allowed amount was less than the $200 copayment, you have been asked to pay $197.52 for these services. 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 MRI you had.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided.
You asked the Plan to waive the copayments for the office visits. You say that you received a bill and want to know why. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each primary care doctor visit for Medicare-covered benefits and a $25 copayment per visit for Medicare-covered specialty care services. You have been asked to pay a $10 copayment for the office visit and a $25 copayment for the office visit. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office visits provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP rental provided by out of network provider.
You asked the Plan to pay for the CPAP rental. You say that you did not realize your authorization had expired. The Plan denied your request. The Plan says you must get your CPCP from an in-network 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 the CPAP rental provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 23, 2019 by the out of network provider.You asked the Plan to pay for the physician service. You say that the provider prescribed you a CPAP machine in November 2018. You say that when you switched plan's in March 2019, you were advised that billing to Medicare would continue, but now it would go through your new insurance provider and nothing additional needed to be done.The Plan denied your request. The Plan says authorization was not obtained before you received the service. The Plan says a plan provider did not refer you for the service. The Plan also says the service was not urgent or emergent.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 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 office visit provided on August 23, 2019 by the out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency ambulance services provided by "the provider" on July 28, 2019.You asked the Plan to waive the copayment forthe ambulance services. You say that you are 88 years old and this bill is too high after being in 2 previous fire rescue without charge.The Plan denied your request. The Plan says you were charged this cost sharing 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 $165 copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $165 for these services. 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 emergency ambulance services provided by "the provider" on July 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided by the out of network provider.
You asked the Plan to pay for the laboratory testing. You say that the blood work is critical to your health. You say that the clinic wants the blood tests to them so they can ensure the accuracy and timely results. You say that the clinic has had numerous problems with the lab in the past. You also say that incorrect or late test results could be detrimental to your health. The Plan denied your request. The Plan says authorization was not obtained before you received the services. The Plan also says you were advised prior to receiving the services that they could be provided in Plan.
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 confirmed there are 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 laboratory testing provided by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the brace provided.
You asked the Plan to waive the coinsurance for the brace. You say that the support didn't work. You say that they would not take it back. The Plan denied your request. The Plan says the coinsurance 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 20% of the Medicare-allowed amount for Medicare-covered durable medical equipment from an in-network provider.
You have been asked to pay $32.85, which is 20% of the allowed amount for the brace. The allowed amount is $164.26 (20% x $164.26 = $32.85). The brace falls 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 for the brace provided.
Your complaint about being scammed is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided by the lab.
You asked the Plan to pay for genetic tests. You say that you are appealing with medical records to support the services billed. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not covered for screening purposes and the enrollee's treating physician did not order the tests.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided by the lab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the visits the enrollee had.
You asked the Plan to waive the copayments. The Plan denied your request. The Plan says the enrollee is responsible for the copayments.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment for each Medicare-covered specialist visit. Review of the file shows that the enrollee had a specialist visit. The enrollee has been asked to pay a $35 copayment for each visit, totaling $70. The visits fall within the physician services visit benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the visits the enrollee had.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy you received.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says two polyps were removed during the procedure.
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 $290 copayment per visit for Medicare-covered outpatient surgery. Review of the file shows that you had a diagnostic colonoscopy. This was not a screening procedure. You have been asked to pay a $290 copayment for the colonoscopy. The colonoscopy 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 colonoscopy you received.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that
were issued.
You asked the Plan to pay for the compression stockings. You say that you bought these stockings because you
were told to wear them following your venous closure procedures. The Plan denied your request. The Plan says
are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a
dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression
stockings identified with code A6533 that were issued.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided by the doctor.
You asked the Plan to pay for the dental service. You say that you had a tooth pulled. You say that it was
mandatory due to an infection. You say that you were very sick and not sure if you would make it. The Plan
denied your request. The Plan says the surgical extraction is not a covered service.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210)
provided.