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

We decided that the Plan does not have to pay for paramedic intercept provided on March 19, 2021.
You asked the Plan to pay for paramedic intercept. The Plan denied your request. The Plan says the ambulance
service is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as
defined above. It is noted that the only State in which these criteria are met is New York.
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic
intercept (A0432) provided on March 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from March 17, 2021, to March 26, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you would like this copayment waived. You said that you were never advised of this cost sharing, and you cannot afford this. The Plan denied your request. The Plan says you were charged this copayment 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 $0 copayment for days 1-20, and a $75 copayment per day for days 21-65 for skilled nursing facility services. 

Records show that you were in the SNF from February 25, 2021, until March 27, 2021, for a total of 30 days.

You were not charged a copayment for the first 20 days of this stay. For the last 10 days, you were charged a $75 copayment per day, for a total of $750. 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 skilled nursing facility (SNF) services you received from March 17, 2021, to March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walker purchased on the internet on June 2, 2021.

You asked the Plan to pay for this walker. The Plan denied your quest. The Plan says the provider you purchased the equipment from is not a eligible Medicare provider.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Durable medical equipment purchased privately through agents on the internet are not eligible for coverage by your Medicare governed health plan. Therefore, we decided that the Plan does not have to pay for a walker purchased on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on July 23, 2021.
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 procedure code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on July 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee from February 18, 2021, to June 2, 2021.  You asked the Plan to pay for these services. You say that these services should be covered y the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 had network providers available who could have provided 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 out of network physician services provided to the enrollee from February 18, 2021, to June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) with a dermatologist on June 29, 2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that the provider's office told you insurance paid the claim and that you don't owe anything. The Plan denied your request. The Plan says the claim was processed correctly meaning you are responsible for a specialist 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 $20 copayment for specialist office visits. You have been asked to pay a $20 copayment for a specialist office visit. Specialist office visits fall within the Physician/Practitioner Services benefit category. The claim clearly indicates the provider billed for $135; however, the Plan only allows the provider to charge $89.05. The Plan paid $69.05, resulting in $20 left to be paid.
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 specialist office visit (99213) with a dermatologist on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a vascular surgeon on July 29, 2021.
You asked the Plan to waive the copayment for the vascular surgery visit. You say that you had an in-home wellness visit. During that visit, you were told to go see a specialist. You said the vascular surgeon and they said that there was nothing wrong with your circulation, so you do not think you should have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 visits with a specialist. You have been asked to pay a $40 copayment for the vascular surgery visit. The vascular surgery visit falls
within the visits with a specialist benefit category. This copayment applies regardless of the reason for the visit. 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 visit you had with a vascular surgeon on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
June 9, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 had network providers available
who could have provided 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 out of network physician services provided to the
enrollee on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 12, 2021.
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 procedure code 85027 is not supported.
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 85027 is blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count). We find that CPT code 85027 is not supported in the medical record. Specifically, there is no documentation
that a complete blood count test was performed for the date of service at issue. 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 for the laboratory services rendered on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214) rendered on April 8, 2021.
You asked the Plan to waive the copayment for an office visit with a specialist. You say that the provider only told you that she was unable to do anything else for you and she did nothing else. You also say that it is strange that the provider billed you for that. The Plan denied your request. The Plan says you were 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 each covered visit or consultation in an outpatient location with a specialist.
You have been asked to pay a $40 copayment for an office visit with a specialist. The records show that you were seen by the provider. There is no provision within the contract which would waive the copayment due to the length of the visit by the provider. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214) rendered on April 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 1, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 had network providers available who could have provided 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 out of network physician services provided to the enrollee on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided January 13, 2021, to January 20, 2021.

You asked the Plan to pay for the critical care. You say that the service was billed correctly. The Plan denied your request. The Plan says the billing of 99291 is not supported for date of service January 13, 2021, to January 20, 2021.

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 asked our coder 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 critical care. Our reviewer says that the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes billed is not supported by the records. Our reviewer found the enrollee was treated with critical care for coronavirus (COVID-19) pneumonia requiring intubation. Current Procedural Terminology (CPT) code, 99291, was utilized for the care provided. Documentation provided however, did not clearly describe the time spent providing the critical care services to support the 30-74 minutes time associated with the procedure code, 99291.

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 critical care have not been met. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided January 13, 2021, to January 20, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the coronavirus testing provided on August 11, 2021.
You asked the Plan to pay for the laboratory services. You say that you were advised to get a coronavirus test. You say that your magnetic resonance imaging (MRI) authorization was approved. You also say that you should not have to pay for this. The Plan denied your request. The Plan says that there are no claims for an MRI on file for August 2021. The Plan also says that the services are not medically reasonable or necessary.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the laboratory services by a contract provider. The file does not show that the Plan provided notice that the laboratory services would not be covered. Under Medicare rules, this means the laboratory services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the coronavirus testing provided on August 11, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital bed (E0301), an air floatation bed (E0193), and a
seat lift mechanism (E0627) provided on January 29, 2021, by a supplier not enrolled in the Medicare program
as a supplier of durable medical equipment.
You asked the Plan to pay for a hospital bed, an air floatation bed, and a seat lift mechanism. You say that the
requested items are a necessity for your care. The Plan denied your request. The Plan says rules for payment
have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program as a supplier of durable medical equipment. Therefore, we decided that the Plan does not have to pay
for a hospital bed (E0301), an air floatation bed (E0193), and a seat lift mechanism (E0627) provided on
January 29, 2021, by a supplier not enrolled in the Medicare program as a supplier of durable medical
equipment
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided on April 27, 2021, by an out-of-network provider.
You asked the Plan to pay for medical services. You say that the enrollee has already established care with the provider of the services at issue and wishes to continue. The Plan denied your request. The Plan says rules for out-of-network care 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 had network providers available who could have provided 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 medical services provided on April 27, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental extractions and surgery (D7210) provided on  July 29, 2021.  You asked the Plan to pay for dental extractions and surgery. You say that the procedure at issue was a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met.  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 dental extractions and surgery (D7210) provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
August 18, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 had network providers available
who could have provided 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 out of network physician services provided to the
enrollee on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an extracapsular cataract removal with
insertion of intraocular lens prosthesis (66984) rendered on June 21, 2021.
You asked the Plan to waive the deductible for an extracapsular cataract removal with insertion of intraocular
lens prosthesis. You say that you were told by the provider that you would not have to pay anything. You also
say that if you knew you would have to pay, you would not have had this service. The Plan denied your
request. The Plan says you were 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 says that there is a deductible applied
here, a $500 deductible for all items and services except those specifically excluded by the Plan contract.
You have been asked to pay $500 for an extracapsular cataract removal with insertion of intraocular lens
prosthesis. An extracapsular cataract removal with insertion of intraocular lens prosthesis falls within the
Outpatient Surgery and Other Medical 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 there is a $500 deductible, which applies to Ambulatory Surgical Centers. This cost sharing is a contractual
obligation that had not been met at the time the extracapsular cataract removal with insertion of intraocular lens
prosthesis (66984) rendered on June 21, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for an extracapsular cataract removal with insertion of intraocular lens prosthesis.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for a rituximab injection (J9312) rendered on January
17, 2020.
You asked the Plan to waive the coinsurance for a rituximab injection. The Plan denied your request. The Plan
says that you were charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan has not provided any evidence of how they calculated your 20%
coinsurance. The burden is on the Plan to show why their assessment of coinsurance was correct, and they have
failed to do so in this case. Therefore, we decided that the Plan has to waive the coinsurance for a rituximab
injection (J9312) rendered on January 17, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.