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

We decided that the Plan does not have to waive the copayment forthe ED visit provided from September 3, 2019 through September 4, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that you were informed the wound was serious enough to be admitted. You say that you would have chosen IV therapy as an outpatient.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 $90 copayment for emergency services in theemergency room.You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you received treatment in the emergency department. 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 ED visit provided from September 3, 2019 through September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Prolia injection provided on June 28, 2019.You asked the Plan to waive the coinsurance forthe Prolia injection. You say that you were informed it would be covered if you received the injections in the office. You say that youshould not be held accountable.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% coinsurance for Medicare Part B covered drugs.You have been asked to pay $224.28, which is 20% of the allowed amount for the Prolia injection. The allowed amount is $1,121.40 (20% x $1,121.40 = $224.28). The Prolia injection falls within the "Medicare Part B prescription drugs" 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 Prolia injection provided on June 28, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided on July 30, 2019.You asked the Plan to pay forthe home 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.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 forthe home health services provided on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic screening testing provided by "the provider" on June 10, 2019.You asked the Plan to pay forgenetic tests. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare prohibited action.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 visitare likewise noncovered.Therefore, we decided that the Plan does not have to pay forgenetic screening testing provided by "the provider" on June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on January 14, 2019 to July 12, 2019 by out of network provider.
You asked the Plan to pay for the chiropractic services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out of 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 chiropractic services provided on January 14, 2019 to July 12, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services received on December 17, 2018.
You asked the Plan to waive the copayment for the services. You say that because these were your yearly labs, this should be covered at 100%. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.
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 $25 copayment for diagnostic lab services. You have been asked to pay a $25 copayment for the services. The services fall within the diagnostic lab 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 waive the copayment for lab services received on December 17, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided to "the beneficiary"  from August 6, 2016 toAugust 7, 2016.You asked the Plan to pay forthe physician services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were filed untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the physician services was not filed until June 27, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe physician services provided from August 6, 2016 to August 7, 2016.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe critical care services coded 99291 and the advance care planning services coded 99497 provided from May 25, 2019 to May 27, 2019.You asked the Plan to pay forthe critical care services and the advance care planning services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 99291 and 99497 are not supported in the medical record. Specifically, the documentationsubmitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. In addition, the submitted medical records do not include sufficient information to support the performance of advance care planning, first 30 minutes was performed. The documented time of 10 minutes if insufficient to support the additional charge. Based on this information, we decided that Medicare rules for coverage of the critical care services and the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay forthe critical care services coded 99291 and the advance care planning services coded 99497 provided from May 25, 2019 to May 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 24, 2019. You asked the Plan to pay forMagnetic Resonance Angiography (MRA) of the Head (70544). You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent and there were in-network providers who can provide the same 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 forthe medical services provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits provided on June 26, 2019, July 24, 2019, August 21, 2019 and September 18, 2019.
You asked the Plan to waive the copayments for the office visits. You say that these are your primary care doctors. 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 $35 copayment for each in-network specialist office visit for Medicare-covered services.
You have been asked to pay a $35 copayment for each office visit. The total amount you owe is $140 ($35/visit x 4 visits = $140). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the providers specialize in Geriatrics. 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 on June 26, 2019, July 24, 2019, August 21, 2019 and September 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe measurement of post-voiding residual urine and/or bladder capacity by ultrasound services coded 51798 provided on May 15, 2019.You asked the Plan to pay forthe measurement of post-voiding residual urine and/or bladder capacity by ultrasound services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 51798 is Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.We find that CPT code 51798 is not supported in the medical record. Specifically, the operative report did not include documentation of measurement of post-voiding residual urine and/orbladder capacity by ultrasound, therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the measurement of post-voiding residual urine and/or bladder capacity by ultrasound services have not been met.Therefore, we decided that the Plan does not have to pay forthe measurement of post-voiding residual urine and/or bladder capacity by ultrasound services coded 51798 provided on May 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe panoramic x-ray provided on February 20, 2019.You asked the Plan to pay forthe panoramic x-ray. You say that the service was medically necessary.The Plan denied your request. The Plan says panoramic x-rays are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe panoramic x-ray provided on February 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam provided on April 17, 2019.
You asked the Plan to waive the copayment for a medical eye exam. You say that you've been going to this doctor for 10 years. You say that this is the first time you have been billed for this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 vision care/medical eye exam. You have been asked to pay a $50 copayment for a medical eye exam. Evidence was provided to show that the correct copayment of a medical eye exam has been applied. A medical eye exam falls within the vision care/medical eye exam 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 a medical eye exam provided on April 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe office visit and Part B drugs provided by on July 17, 2019.You asked the Plan to waive the cost share forthe office visit and Part B drugs. You say that you shouldn't have a copayment because you never saw a physician. You say that you cannot afford the copayments.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for provider and professional services at an in-network specialist's visit. Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B covered drugs at an in-network specialist's office. You have been asked to pay a total of $52.11 for the office visit and Part Bdrugs. Date of ServiceServiceAllowed AmountStandard Cost ShareMember LiabilityJuly 17, 2019Office Visit$59.82$40$40July 17, 2019Iron Sucrose Injection$6020%$12July 17, 2019Saline Infusion$0.5320%$0.11TOTAL:$52.11
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B drugs fall within the "Medicare Part B prescription drugs" 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 cost share forthe office visit and Part B drugs provided by on July 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinterspinous process decompression (22869).You asked the Plan to pre-approveinterspinous process decompression. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's scoliosis means this service is not medically necessary.The Plan follows Medicare rules. Medicare rules say that interspinous process decompression is covered only for enrollees who meet all of the above criteria and none of the limitations.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve interspinous process decompression. 
Our reviewer says that Medicare criteria have not been met. Our physician reviewer found the physical examinations of the lumbar spine by the physician document pain on flexion and extension, rather than relief of symptoms in flexion. Furthermore, X-rays of the lumbar spine revealed scoliosis, concave to the left, centered at the L1-L2 disc space level. There is no documentation of the Cobb angle. There is documented mild (grade 1) retrolisthesis of L2 on L3, and grade 2 anterolisthesis of L4 on L5.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of interspinous process decompressionhave not been met.Therefore, we decided that the Plan does not have to pre-approveinterspinous process decompression (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyperbaric Oxygen Therapy (99183 and G0277).You asked the Plan to pre-approveHyperbaric Oxygen Therapy. You say that this is medically necessary due to theenrollee's radiation level.The Plan denied your request. The Plan says HBO therapy is not covered for a tooth extraction.The Plan follows Medicare rules. Medicare rules say that HBO therapy is covered only for the above listed 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 pre-approve Hyperbaric Oxygen Therapy. Our reviewer says that the documentation does not support that the requested HBO therapy is currently medically necessary or reasonable. Our physician reviewer found the enrollee is noted to have a history of tongue cancer, for which he apparently received chemotherapy and radiation. The enrollee is now in need of a dental extraction, for which HBOT has been ordered to apparently prevent the development of osteoradionecrosis. There is no evidence that the enrollee currently has osteoradionecrosis, or any other condition for which HBOT s indicated (ex. CO poisoning, necrotizing infection, soft tissue radionecrosis). HBOT is not covered as a prophylactic therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyperbaric Oxygen Therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveHyperbaric Oxygen Therapy (99183 and G0277).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit or the infusions
provided on July 24, 2019.
You asked the Plan to waive the cost share for the specialist office visit and the infusions. You say you would
have never agreed to receive the service because you would not have been able to afford the copayment. The
Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for provider and professional services at an in-network specialist's office and 20% coinsurance for
Medicare Part B covered drugs at an in-network specialist's office.
You have been asked to pay a total of $52.11 for the specialist office visit and the iron infusion. The specialist
office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.
The infusion falls within the "Medicare Part B prescription drugs" benefit category. See charge below.
Date of Service Service Allowed Amount Copayment/Coinsurance Member
Liability
July 24, 2019 Specialist office
visit
$59.82 $40.00 $40.00
July 24, 2019 Iron infusion $60.00 20% $12.00
July 24, 2019 Saline infusion $0.53 20% $0.11
Total $52.11
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 specialist office visit or the infusions provided on July 24,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on June 21, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.Review of the file shows that no progress notes were provided to support that the serviceswere not provided for screening purposes. The documentation does not support that the laboratory testing at issue in this appeal was not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on June 21, 2019.