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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from March 17, 2021, through March 27, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not in the hospital during this time. The Plan denied your request. The Plan says the copayment was 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 $360 copayment per day for days 1-5, then $0 copayment per day after day 5 for inpatient hospital care. You have been asked to pay a $1800 ($360 x 5 = $1800) copayment for inpatient hospital care. The services at issue fall within the inpatient hospital care 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 inpatient hospital care from March 17, 2021, through March 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to issue reimbursement for the office visit (99213) rendered by the out-of-network (OON) provider on March 16, 2021.
You asked the Plan to issue reimbursement for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.
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. Specifically, the Plan has not provided the Evidence of Coverage (EOC) booklet that indicates the Plan contract coverage. Therefore, we decided that the Plan has to issue reimbursement for the office visit (99213) rendered by the out-of-network (OON) provider on March 16, 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by the out-of-network (OON) provider on April 9, 2021, April 19, 2021, April 29, 2021, May 10, 2021, May 13, 2021, May 17, 2021, and May 20, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 psychotherapy services (90837) rendered by the out-of-network (OON) provider on April 9, 2021, April 19, 2021, April 29, 2021, May 10, 2021, May 13, 2021, May 17, 2021, and May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the removal of recurring cataract in lens capsule using a laser (66821) provided June 9, 2021.
You asked the Plan to waive the cost share for the removal of recurring cataract. You say that you did not realize you would be charged a cost share. The Plan denied your request. The Plan says there is a $750 deductible that must be met before relevant cost shares will apply.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to outpatient surgery. The item or service you asked the Plan to waive the cost share for falls within the benefit category outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the removal of recurring cataract was received on June 9, 2021. Therefore, we decided that the Plan does not have to waive the cost share for the removal of recurring cataract in lens capsule using a laser (66821) provided June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on
April 30, 2021.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says this is not separately payable.
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, we have confirmed that code 70450
has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on April 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided May 17, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you did not want the ambulance services and the copayment will be difficult to pay. The Plan denied your request. The Plan says the copayment was 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 $225 copayment for each one-way Medicare-covered ambulance trip. You have been asked to pay a $225 copayment for the ambulance services. This service falls within the Ambulance 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on March 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered
service.
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 for the chiropractic services provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA (CPT code(s): 64633 and 64634), for the enrollee.
You asked the Plan to pre-approve the RFA. You say that within the last three (3) months the enrollee has experienced moderate to severe pain. You state the enrollee has tried nonsteroidal anti-inflammatory drugs (NSAIDS) and physical treatments that have not worked. The Plan denied your request. The Plan says repeat RFA is not medically necessary because more than two (2) years have elapsed since the prior RFA of this area.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the RFA have not been met. The medical record submitted on appeal indicates the enrollee had significant (80-90%) improvement in pain following prior RFA procedures in this area which were performed in September 2018. The rules say limitations: If there is an extended time, two years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated. Therefore, we decided that the Plan does not have to pre-approve RFA (CPT code(s): 64633 and 64634), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Gel-One injection (J7326) provided on March 23, 2021.
You asked the Plan to waive the coinsurance for a Gel-One injection. You say that this did not help you so you should not be charged. The Plan denied your request. The Plan says this processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for a Gel-One injection, which is a Medicare Part B prescription drug. 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 a Gel-One injection (J7326) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS device (E0730) and electrical stimulator leads
(A4595) provided on March 12, 2021.
You asked the Plan to pay for a TENS device and electrical stimulator leads. You say that the requested item is
a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for a TENS
device and related supplies have not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare will cover a TENS device for CLBP
when the enrollee is enrolled in an approved clinical study.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a TENS device and electrical stimulator leads have not been met. Specifically, there is no
indication that the enrollee is enrolled in an approved clinical study. Therefore, we decided that the Plan does
not have to pay for a TENS device (E0730) and electrical stimulator leads (A4595) provided on March 12,
2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on September 10,
2020.
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 due to the enrollee's hospice status at the time of service, this claim should be submitted
to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
medical services provided to the enrollee on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hydration infusion services provided to the enrollee on March 31, 2021.
You asked the Plan to pay for the services. You say that the enrollee had previous dates of service with these same procedures, and they were paid. The Plan denied your request. The Plan says Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.
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 hydration infusion services provided to the enrollee on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture (D5214) or pay more for the complete maxillary denture (D5110) provided on March 29, 2021.
You asked the Plan to pay for the mandibular partial denture and to pay more for the complete maxillary denture. You say that the only reason you switched to this plan was because you needed dentures, and the agent said they would be covered under this plan. You also say that you contacted the Plan and were told you would be responsible for two copayments of $195, and a limit of $1,000. The Plan denied your request. The Plan says the annual maximum benefit provision of your benefit plan was reached for this claim. The Plan also says that at no time were you advised that the Plan would pay anything beyond your $1,000 allowance.
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 Plan offers a max allowance amount of $1,000 per year for supplemental comprehensive dental services. The contract says that you are responsible for all costs over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the March 29, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the mandibular partial denture (D5214) or pay more for the complete maxillary denture (D5110) provided on March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from April 7, 2021, to April 11, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the hospital stay was related to coronavirus and therefore should be covered. The Plan denied your request. The Plan says the copayment was 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 $750 copayment for each Medicare-covered hospital stay for unlimited days after your $500 deductible is met. You have been asked to pay a total of $806 for the inpatient hospital stay. At the time of the service, you had $56.17 remaining in your deductible. After the deductible was met, you were responsible for the $750 copayment for the hospital service ($56.17 remaining deductible + $750 copayment = $806.17). The inpatient hospital stay falls within the Inpatient hospital care benefit category. While Medicare covers items and services related to COVID-19 including medically necessary hospitalizations, you'll still pay for any hospital deductibles, copays, or coinsurances that apply. 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 inpatient hospital stay from April 7, 2021, to April 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided on March 1, 2021.
You asked the Plan to pay for outpatient mental health care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the provider is not an eligible Medicare provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider.
The enrollee was not referred and did not have prior authorization. Therefore, we decided that the Plan does not
have to pay for outpatient mental health care provided to the enrollee on March 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on May 12, 2021.
You asked the Plan to waive the copayment for vision services. You say that you should not have a copayment 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 $20 copayment for vision care/in-network/eye exam. You have been asked to pay a $20 copayment for vision services. The correct copayment has been vision services fall within the vision care/in-network/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 vision services provided by a participating provider on May 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found based on review of the available records, the enrollee does not meet criteria for
an IRF admission. There is no documentation of any nursing needs. Documentation does not support the need
for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week. While he may
benefit from physical therapy, and occupational therapy, there is no evidence of need for an intensive therapy
program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to
rehabilitation care. The enrollee's rehabilitation needs can be easily met at a less intense and alternate level of
setting such as in a Skilled Nursing Facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140)
provided on May 11, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that no one informed you
of an over payment. The Plan denied your request. The Plan says you have exceeded your maximum 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 Plan offers a $2,500 annual dental
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are
responsible for the full charges of any additional dental services. The record shows that you met the annual
maximum benefit on April 16, 2021 and your annual maximum benefit has been exhausted. Therefore, we
decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on
May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (CPT code 92015) provided on October 21, 2020.
You asked the Plan to pay for the eye refraction. You say that you were in the office on October 21, 2020, and you did not have a refraction which appears on your bill. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. Review of the medical records show that you had a Medicare covered (medical) eye exam, which does not include the refraction. Your 2020 EOC states that covered services include: Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. Furthermore, your complaint is not a valid appeal for medical coverage for CPT code 92499. After looking at all of the information in this case, we found that you do not owe any money or unlisted ophthalmological service or procedure (CPT code 92499). Since you owe no money, there is no need for a coverage decision for CPT code 92499. If the provider is billing you for charges beyond any applicable cost-sharing amounts, please contact the Plan directly. The Plan has instructed the provider to cease balance billing.
Therefore, we decided that the Plan does not have to pay for the eye refraction (CPT code 92015) provided on October 21, 2020.