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

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on November 25, 2020.
You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 code 99233 is not supported in the medical record. Specifically, the documentation shows that this code was previously submitted, processed, and paid by the plan for this date of service. This means this is a duplicate service and cannot separately paid. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on November 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper endoscopy provided on February 10, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 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 the upper endoscopy provided on February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for anticoagulation management services you received from a cardiologist on April 12, 2021, and April 23, 2021.
You asked the Plan to waive the copayments for the anticoagulation management services. You say that these services should be considered lab services and no copayment should apply. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for each date of service ($11.67) is less than your copayment obligation, you are responsible for the full allowed 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 services with a specialist.
You have been asked to pay a $40 copayment for the anticoagulation management services. The procedure code that was billed for anticoagulation management (93793) is considered a physician service, not a lab service. That is why the anticoagulation management services falls within the services with a specialist 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 anticoagulation management services you received from a cardiologist on April 12, 2021, and April 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the central motor evoked potential study provided on June 24, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the 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 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 the central motor evoked potential study provided on June 24, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the health and well-being coaching services (0592T)
provided January 6, 2021 to February 25, 2021.

You asked the Plan to pay for the health and well-being coaching services. You say that you were diagnosed
with anxiety, panic attacks, ulcerative colitis and COPD. You need the therapy and coaching sessions. The Plan
denied your request. The Plan says the services provided are naturopathic services which are not covered by
Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.

The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have
to pay for the health and well-being coaching services (0592T) provided January 6, 2021 to February 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the brain you had on April 28, 2021.
You asked the Plan to waive the copayment for the MRI. You say that this copayment should be waived
because this service was needed as a result of your second vaccine for the Coronavirus. The Plan denied your
request. The Plan says this copayment was charged 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 $200
copayment for diagnostic and nuclear medicine radiological services.
You have been asked to pay a $200 copayment for the MRI. the MRI falls within the diagnostic and nuclear
medicine radiological services benefit category.
This copayment applies regardless of the reason why you had the 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 magnetic resonance imaging (MRI) of the brain you had on April 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (47542) provided March 16, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
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 code 47542 is not supported in the medical record. Specifically, modifier 51 was billed inappropriately for the add-on code. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (47542) provided March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on March 4, 2021 to
March 13, 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 the claim was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with place of
service (POS) code 21.
We looked at the file and Medicare rules. The file shows that the inpatient services were not billed with the
required POS code 21. 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 subsequent
hospital care rendered on March 4, 2021 to March 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies (A4231, A4323) provided March 11, 2021.
You asked the Plan to pay for the diabetic supplies. You say that the items were medically necessary. The Plan
denied your request. The Plan says the billed codes are not eligible for Medicare payment. The provider must
bill the correct codes.
The Plan must follow Medicare rules. Medicare rules say that current procedure terminology (CPT) Codes
A4231 and A4323 are invalid for submission to Medicare and are non-covered.
We looked at the file and Medicare rules. Medicare rules state that the billed codes are invalid for Medicare
payment. Based on this information, we decided that Medicare rules for coverage of the diabetic supplies have
not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies (A4231, A4323)
provided March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 services provided by an out-of-network provider on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 19, 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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was 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 for the laboratory services rendered on March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the pacemaker insertion procedure you had at an outpatient hospital facility from May 5, 2021, to May 6, 2021.
You asked the Plan to reduce the coinsurance for the outpatient procedure. You say that the doctor on call completed the paperwork incorrectly because this was supposed to be an inpatient admission. The Plan denied your request. The Plan says you were charged this amount correctly because this was billed and ordered as an outpatient, not inpatient, surgery. The Plan says that authorization for this procedure was requested as an outpatient, not inpatient.
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 outpatient surgery at an outpatient hospital facility.
You have been asked to pay 20% coinsurance for the outpatient procedure. 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 reduce the coinsurance for the pacemaker insertion procedure you had at an outpatient hospital facility from May 5, 2021, to May 6, 2021.
Your complaint about how the doctor coded this stay 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on May 11, 2021.
You asked the Plan to waive the copayment for these services. You say that the x-rays were done at the same time to the same area. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copayment for each specialist visit for Medicare-covered services.
Review of the file shows that you received specialist services on May 11, 2021. The copayment you are being asked to pay is for the specialist services, not the x-ray. Per the contract with the Plan, there is a $45 copayment for each specialist visit for Medicare-covered services. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. However, the Medicare allowed amount for these services was $34.58. Given that the allowed amount was less than the $45 copayment, you have been asked to pay $34.58 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on May 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on November 2, 2020 and December 2, 2020.

You asked the Plan to pay for these services. You say that these claims 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 must 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 lab services provided to the enrollee on November 2, 2020 and December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1851, L2397) provided on January 26, 2021.

You asked the Plan to pay for a knee brace. You say that this is supported by the records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid physician order or proof of delivery for the supplies provided in this case.

The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee brace (L1851, L2397) provided on January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medial eye exam (99214) provided on
April 26, 2021.

You asked the Plan to waive the copayment for a medical eye exam. You say that you made an appointment to
have your vision checked since you have had intraocular lenses in your eyes for many years and you are unable
to see with your current lenses. The Plan denied your request. The Plan says the copayment you are being
charged is 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 a $45
copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. for vision
care.

You have been asked to pay a $45 copayment for a medical eye exam. The EOC confirms that $45 is the required copayment for this service. A medical eye exam falls within the vision 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 a medial eye exam (99214) provided on April 26, 2021.

Your complaint about the eye exam 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 the molecular pathology services rendered on February 8, 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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. 

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology services rendered on February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient rehabilitation provided by from December 4, 2020, through December 21, 2020.
You asked the Plan to pay for inpatient rehabilitation. You say that you did not know that this hospital was not a network facility, and you assumed it would be because it is located within your community. The Plan denied your request. The Plan says the services received were not considered "emergency or urgently needed" services that would fall under the exception for coverage of out-of-network providers.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for inpatient rehabilitation provided from December 4, 2020, through December 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on April 9, 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 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 April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a back-up battery.

You asked the Plan to pre-approve a back-up battery. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says a back-up battery is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a back-up battery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have arthritis in your foot and ankle. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.