Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on June 17, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you do not believe you should pay a copayment for the visit that pertains to the skin cancer surgery on June 17, 2021. 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 $45 copayment for physician specialist services (including surgery second opinion, telehealth services, and urgently needed services).

You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on June 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on July 15, 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 medical services provided to the enrollee on July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on April 13, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal the self-administered drugs. The Plan denied your request. The Plan says this claim was processed correctly according to your plan benefits.

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 pay for the self-administered drugs provided on April 13, 2021.

Benefits for the self-administered drugs 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for debridement services (procedure code 11042) provided to the enrollee on November 23, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an add-on code.  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 11042 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for debridement services (procedure code 11042) provided to the enrollee on November 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 2, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on November 2, 2020.

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 laboratory services rendered by the out-of-network (OON) provider on November 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on April 6, 2021.

You asked the Plan to waive the copayment for the laboratory work. You say that you believe the laboratory work should be a part of your annual physical. You say had the laboratory work done the following day. 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 $10 copayment per day for other Medicare-covered laboratory tests that are not fecal immunochemical tests (FIT).

You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that laboratory work is considered a separate service from the annual physical. 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 laboratory work provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and services provided from January 28, 2021, to February 1, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that the enrollee was dissatisfied with the treatment provided and checked out early. The enrollee feels they should not be responsible for this copayment and the Plan should rescind payment as well. The Plan denied your request. The Plan says this claim was processed correctly for the dates the enrollee received care, and the cost-share was assessed in accordance with the contract.

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 $195 copayment for each of the first five days of inpatient hospital care.

The enrollee has been asked to pay a $780 copayment for the four-day inpatient stay ($195 x 4 = $780). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient admission and services provided from January 28, 2021, to February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided March 8, 2021, and the apicoectomy - premolar (first root) (D3421) and intraoral - periapical first radiographic image (D0220) provided March 25, 2021.

You asked the Plan to pay for the limited oral exam, cone bean CT scan, apicoectomy and intraoral x-ray. You say that the services should be covered. The Plan denied your request. The Plan says these services are not covered under your benefits.

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 limited oral evaluation - problem focused (D0140) and cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364) provided March 8, 2021, and the apicoectomy - premolar (first root) (D3421) and intraoral - periapical first radiographic image (D0220) provided March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from August 2, 2020, through August 8, 2020 billed with principal diagnosis code A41.9.

You asked the Plan to pay for the inpatient services as billed. You say that this claim was billed correctly with the correct DRG. The Plan denied your request. The Plan says the principal diagnosis is not supported meaning that the DRG as billed is not appropriate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 

In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as Sepsis unspecified organism. 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 pay for the inpatient services as billed. Our reviewer says that the documentation does not support the use of A41.9 as the principal diagnosis for this admission. Our physician reviewer found the patient presented to the emergency room and was found to have bilateral hydronephrosis and was admitted for urinary retention. Sepsis is not documented as a current status during emergency room care. On 8/4, a consultation was performed for acute mental status change, leukocytosis, and probable urinary tract infection. Sepsis is not documented during this visit. On August 7, 2020 a consultation was performed for Atrial Fibrillation, sepsis is not documented in this visit. Sepsis is listed as a discharge diagnosis; however, no plan of treatment was documented for this diagnosis, through the course of admission. Documentation throughout this hospital admission is not clear and consistent to confirm a primary diagnosis of Sepsis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from August 2, 2020, through August 8, 2020 billed with principal diagnosis code A41.9.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the breast (76642) provided on June 14, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that this was part of your mammogram and should have a $0 copayment. The Plan denied your request. The Plan says the ultrasound is a separate service from a mammogram. You are responsible for a $100 copayment for ultrasounds. You are being asked to pay less than this amount because the allowed/discounted rate is less than your required copay.

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 $100 copayment for Medicare-covered diagnostic radiology services.

You have been asked to pay a $95.48 copayment for the ultrasound. A mammogram is one distinct service, and an ultrasound is a separate service. Ultrasounds fall within the Medicare-covered diagnostic radiology 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 ultrasound of the breast (76642) provided on June 14, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427, A0428) provided on May 25, 2021, and May 29, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you cannot afford these bills due to financial difficulties and believed copayments related to COVID-19 were being waived. The Plan denied your request. The Plan says these services are covered benefits, and these claims were processed correctly. You are responsible for a $250 copayment for each one-way Medicare-covered ground ambulance trip.
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 $250 copayment for ambulance services.
You have been asked to pay a $250 copayment or less for each of the ambulance transport trips. 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 transportation services (A0427, A0428) provided on May 25, 2021, and May 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health visit you had
on September 9, 2021.
You asked the Plan to waive the copayment for the outpatient mental health visit. You say that you cannot
afford 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 $25
copayment for outpatient mental health services.
You have been asked to pay a $25 copayment for the outpatient mental health 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 outpatient mental health visit you had on
September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 1, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the breast ultrasound (76642) provided on June 4, 2021.

You asked the Plan to waive the copayment the ultrasound. You say that you were not aware you would owe a copay for this service, as you have had ultrasounds in the past where you did not owe a cost-share. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. The Plan also notes that you have not had this specific ultrasound, billed with code 76642, before.

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 $100 copayment for Medicare-covered diagnostic radiology services.

You have been asked to pay a $93.87 copayment for the ultrasound. Ultrasounds fall within the Medicare-covered diagnostic radiology 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 the breast ultrasound (76642) provided on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on July 26, 2021 and crown provided on August 5, 2021.

You asked the Plan to pay for the resin-based composite and crown. You say that the Plan is supposed to cover $2,000 of dental claims a year and you want to be reimbursed for the remaining amount. The Plan denied your request. The Plan says the frequency limitation has been exceeded.

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, you also have a maximum benefit of two resin-based composites per calendar year and one crown per calendar year. The Plan paid for two resin-based composites provided on May 26, 2021 and paid for the crown provided on June 1, 2021, which exhausted your benefits. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on July 26, 2021 and crown provided on August 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services reported with code A0999 on date of service April 12, 2021.
You asked the Plan to pay for the ambulance services. You say that you billed this service correctly. The Plan denied your request. The Plan says Medicare medical necessity criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. You did not provide transport services on April 12, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services reported with code A0999 on date of service April 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for skilled nursing facility (SNF) and physical therapy services provided from June 1, 2021, to June 28, 2021.

You asked the Plan to waive the copayments for the SNF and physical therapy services. You say that you did not need to be there more than 20 days. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $184 per day for days 21-100 for each skilled nursing facility (SNF) stay. Your contract with the Plan also clearly states that you must pay a $20 copayment for each outpatient rehabilitation service, including physical therapy. 

The record shows you were in a skilled nursing facility (SNF) from May 26, 2021, to June 18, 2021. Your stay lasted 24 days. Therefore, you have been asked to pay $184 per day for four days of SNF services. The total for your stay is $736. Skilled nursing facility (SNF) services fall within the Skilled Nursing Facility (SNF) Care benefit category. You have also been asked to pay $120 for physical therapy services ($20 copayment x 6 visits = $120). The record shows you were no longer in a skilled nursing facility when physical therapy services were received. Physical therapy services fall within the Outpatient Rehabilitation 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 copayments for skilled nursing facility (SNF) and physical therapy services provided from June 1, 2021, to June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oligomeric proanthocyanidins (OPC-3) purchased on February 5, 2021.

You asked the Plan to pay for the OPC-3. You say that you have taken this to help with asthma for over 15 years and it has benefited you in other ways. You say that given the amount of research regarding the wide range of benefits this should be included in the Picks Your Perks program and reimbursement should be approved. The Plan denied your request. The Plan says this is not covered under this benefit.

You have $550 through the Pick Your Perks Benefit program for eligible expenses. OPC-3 is not an eligible item. Therefore, we decided that the Plan does not have to pay for the OPC-3 purchased on February 5, 2021.