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

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care, provided on April 1, 2021, through April 23, 2021.

You asked the Plan to waive the copayment for the SNF care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share 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 $184 copayment for days 21-100 for skilled nursing facility (SNF) care. 

You have been asked to pay a $184 copayment for days 21-100 for the SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. Our records indicate you were in the Skilled nursing facility for 24 days, the first 20 days were covered, and you were responsible for a copay for the remaining 3 full days ($184 x 3 days = $552). 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 skilled nursing facility (SNF) care, provided on April 1, 2021, through April 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428, A0425) provided on March 3, 2021.  You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you are unable to afford the copayment. 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 $245 copayment for ambulance services.   You have been asked to pay a $245 copayment for non-emergency ambulance transportation. The service at issue 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 non-emergency ambulance transportation (A0428, A0425) provided on March 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusions provided from February 2, 2021, through February 23, 2021.  You asked the Plan to pay for the home infusions. You say that the provider is in-network and the claim is being incorrectly processed. You say that the claim should be reviewed and reprocessed for payment. The Plan denied your request. The Plan says the codes are not valid for Medicare billing purposes.  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 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). The CPT Code Manual definition of code 99602 is home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure).  The CPT Code Manual definition of code S9338 is home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.  We find that CPT code 99601, 99602 and S9338 are not supported in the medical records. Specifically, the billed CPT codes have a status indicator of I. This means that the codes are not valid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the home infusions have not been met. Therefore, we decided that the Plan does not have to pay for the home infusions provided from February 2, 2021, through February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81286, 81238, 81410, 81411) provided May 1, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  We looked at the file and Medicare rules. The tests at issue were not ordered by the treating physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81238, 81410, 81411) provided May 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hydroxyzine pamoate.  You asked the Plan to pre-approve hydroxyzine pamoate. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve hydroxyzine pamoate.   Benefits for hydroxyzine pamoate may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 29, 2021, through August 1, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be responsible for the copayment. 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 $275 copayment per day for days 1-5 for inpatient hospital care. 

You have been asked to pay a $825 copayment ($275 x 3 = $825) 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 provided from July 29, 2021, through August 1, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the urinary tract infection testing provided on August 2, 2021, billed with 12 units of 87798.  You asked the Plan to pay for the urine testing. You say that this should be paid. The Plan denied your request. The Plan says that these services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.  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 failed to provide a cogent denial rationale for the services at issue in this case. It is noted that these services were denied as screening in nature and that they had no relation to a medical diagnosis. This is directly contradicted by the record and by the diagnosis codes reported on the claim. The testing was ordered due to symptoms of dysuria and polyuria. Testing for urinary tract infectious agents in this setting cannot be considered a screening test. With no valid denial rationale, we find that the criteria for coverage of this testing have been met. Therefore, we decided that the Plan has to pay for the urinary tract infection testing provided on August 2, 2021, billed with 12 units of 87798.   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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from March 9, 2021, to March 12, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that you were admitted as an inpatient and should not owe the emergency room copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for emergency services in an in-network emergency room. 

You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you were billed for observation which is considered an outpatient service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided from March 9, 2021, to March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the telehealth services rendered from December 15, 2020 and February 9, 2021.  You asked the Plan to waive the copayment for these services. You say that all of the services were virtual visits. The Plan denied your request. The Plan says the copayments were 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 specialist visit in 2021 and a $30 copayment for each specialist visit in 2020.  Review of the file shows that you had a specialist visit on December 15, 2020. You have been asked to pay a $30 copayment for these services. These services fall within the telehealth specialist visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.   The file shows that you had a specialist visit on February 9, 2021. You have been asked to pay a $35 copayment for these services. These services fall within the specialist visit benefit category. The Plan contract says that the copayment for telehealth visits is the same as for in-person visits in 2021. This means that you have been asked to pay the correct amount based on your contract with the Plan.  The total amount you have been asked to pay for these services is $65. 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 telehealth services rendered from December 15, 2020 and February 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for infrared therapy (97026) provided on July 15, 2021.  You asked the Plan to pay for infrared therapy (97026). The Plan denied your request. The Plan says that CPT code 97026 infrared therapy is non-covered for all indications.  The Plan must follow Medicare rules. Medicare rules say that infrared therapy is non-covered for all indications.   We looked at the file and Medicare rules. Medicare says infrared therapy is non-covered for all indications Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) provided on  July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialist services rendered on June 28, 2021.  You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $40 copayment for each in-network, in-person specialist visit.   Review of the file shows that you received specialist services on June 28, 2021. You have been asked to pay a $40 copayment for these services. These services fall within the in-network, in-person specialist visit 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 specialist services rendered on June 28, 2021.   Your complaint about the provider 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 pay for dermatologist services (99213, 17110, 17004) provided on June 21, 2021, by a provider that has opted out of Medicare.  You asked the Plan to pay for dermatologist services. You say that you have out-of-network benefits. The Plan denied your request. The Plan says the provider at issue does not accept Medicare.  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 has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dermatologist services (99213, 17110, 17004) provided on June 21, 2021, by a provider that has opted out of Medicare.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70450) provided July 13, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and 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 is a column II code to column I code 70496.   This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70450) provided July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059) provided on August 4, 2021.  You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain fused to metal crown. You say that you feel the crown should be covered. The Plan denied your request. The Plan says these services are not covered under your plan.  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 the custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059) provided on August 4, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the glycated hemoglobin testing provided on May 6, 2021.  You asked the Plan to pay for the glycated hemoglobin testing. You say that you realize that you may have signed something that remove your rights to appeal, but you feel that you were not given information as to why this would be denied. You feel that this practice is not appropriate and takes advantage of the elderly. The Plan denied your request. The Plan says that you signed a form saying that you would be responsible for payment of this test if it was not covered. Therefore, it was denied correctly and is your responsibility.  The Plan must follow Medicare rules. Medicare rules say that glycated hemoglobin may be medically necessary for patients with diabetes up to once every three months.   In this case, although this was billed with a modifier saying that you accepted responsibility if this test was not covered, this does not remove the Plan's responsibility to provide a valid reason for non-coverage on appeal. The form you signed indicates only that the lab believed this might be denied, but does not in itself constitute a valid reason for denial. Review of the records show that your last test of this type was in January 2021, more than three months prior to this test. The records also show that you reported higher than normal blood sugar values to your doctor which was the reason that this testing was ordered. Your network provider ordered this testing, not informing you that it might not be covered, and it was not provided less than three months after your prior test of this type. We find no valid rationale for denial of this testing exists based on the information in the file, and no rationale was provided by the Plan. As such, we find that the rules for coverage of this testing have been met. Therefore, we decided that the Plan has to pay for the glycated hemoglobin testing provided on May 6, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound care services provided on September 1, 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 wound care services provided on September 1, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered from August 18, 2021 to August 19, 2021.  You asked the Plan to waive the copayment for these services. You say that the doctor told you to go to the ER. 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 $90 copayment for emergency room services.   You have been asked to pay a $90 copayment for these services. these services falls within the emergency room 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 emergency room (ER) services rendered from August 18, 2021 to August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (C8929) provided August 16, 2021.  You asked the Plan to waive the copayment for the imaging services. You say that you should have been informed that there would be an extra cost. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.  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 10% coinsurance for each Medicare covered service. $75 out of pocket maximum per day.  You have been asked to pay $75 for the imaging services. the imaging services falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (C8929) provided August 16, 2021.