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

We decided that the Plan does not have to waive the coinsurance for albuterol provided from February 23, 2021, to July 13, 2021.

You asked the Plan to waive the coinsurance for albuterol. You say that you have never had a copayment before and were not told there would be a copayment for the medicine. You also say that due to the provider not providing the equipment, you should not be responsible for this copayment. 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 20% coinsurance for each Part B drug.

You have been asked to pay a total of $7.20 coinsurance, which is 20% of the allowed amount for albuterol.

Albuterol fall within the Medicare Part B Prescription Drugs 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 coinsurance for albuterol provided from February 23, 2021, to July 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex extremity scan rendered on
February 17, 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 $50
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.

Review of the file shows that you received a duplex extremity scan on February 17, 2021. You have been asked
to pay a $50 copayment for these services. These services fall within the diagnostic procedures and tests,
including ultrasounds, at all locations of service 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 duplex extremity scan rendered on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 26, 2021 by an OON provider.

You asked the Plan to pay for the dental services. You say that you have been going to the same dentist for years and your claim has always been paid. You also say that you were unaware that this provider was OON with your plan. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that your plan does not provide coverage for OON providers.

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 are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), first intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), bitewing x-rays (D0274), and prophylaxis (D1110) provided on May 26, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided from May 26, 2021, to May 28, 2021.

You asked the Plan to waive the coinsurance for inpatient hospital services. You say that you were located in a hallway, which is not considered a room. You also say there was a lot of noise from the nurse's station and people who passed in the hallway. 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 a $250 copayment per admission for inpatient hospital care. 

The record shows you received inpatient hospital services. You have been asked to pay a $250 copayment for inpatient hospital services. Inpatient hospital services 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 coinsurance for inpatient hospital services provided from May 26, 2021, to May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, temporomandibular joint, open and closed mouth (70300) provided on September 8, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic service. You say that please review the attached medical records showing the medical necessity for the services. You were not aware that the enrollee had the Plan and originally billed the claim to Medicare and no prior authorization was needed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 radiologic examination, temporomandibular joint, open and closed mouth (70300) provided on September 8, 2020 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from May 7, 2021, through
May 31, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the SNF services. 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 SNF services provided from May 7, 2021, through
May 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided on June 3,
2021.

You asked the Plan to waive the coinsurance for the medical supplies. You say that there should be no
coinsurance for these items because they were part of home health services. The Plan denied your request. The
Plan says this coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees
must pay 20% coinsurance for medical supplies.

The enrollee has been asked to pay 20% coinsurance for the medical supplies. The Evidence of Coverage says
that under the home health benefit, there is still 20% coinsurance for medical equipment and supplies. 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 coinsurance for medical supplies provided on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two cataract surgeries you had on
February 24, 2021, and March 11, 2021.

You asked the Plan to waive the copayments for the two cataract surgeries. You say that you were told that
each surgery would only cost $225, so you should not have to pay the additional cost. The Plan denied your
request. The Plan says you were charged these copayments 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 $300
copayment for outpatient surgery services.

You have been asked to pay a $300 copayment for each of the two cataract surgeries. 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 the two cataract surgeries you had on February 24, 2021, and March 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on May 21, 2021.

You asked the Plan to waive the copayment for outpatient mental health care. You say that you request that your copayments be waived. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for outpatient mental health care. 

You have been asked to pay a $35 copayment for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 outpatient mental health care provided on May 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the fluoroscopy services (76000) provided
February 23, 2021.

You asked the Plan to waive the deductible for the fluoroscopy services. You say that these services were not
performed, and you should not be billed for them. The Plan denied your request. The Plan says the deductible
has processed correctly as they confirmed the service was performed.

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 $500 deductible which applies to outpatient diagnostic tests,
therapeutic services, and supplies.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
diagnostic tests, therapeutic services, and supplies. The Plan has followed Medicare rules by clearly disclosing
in the contract that there is a $500 deductible which applies to outpatient diagnostic tests, therapeutic services,
and supplies. This cost sharing is a contractual obligation that had not been met at the time the fluoroscopy
services was received on February 23, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for the fluoroscopy services (76000) provided February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99222) provided October 17, 2019.

You asked the Plan to pay for the initial hospital care. You say that the medical records attached support the service rendered. Please review and reconsider for payment. The Plan denied your request. The Plan says this exceeds the contracted maximum number of hours/days/units by this provider for this period.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

In this case, the CPT Code Manual definition of code 99222 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity.

We find that the records show that the exact service 99222 was already billed for this enrollee, for the same date of service by the same provider. This other claim paid on April 15, 2020. Per the AMA CPT Manual, this is a per diem service, which can only be billed once per day for the same provider, so it would be inappropriate to reimburse the service more than once per day. The units of CPT code 99222 are not supported in the medical record. Per the AMA CPT Manual, this is a per diem service, which can only be billed once per day for the same provider, so it would be inappropriate to reimburse the service more than once per day. units of CPT code 99222. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99222) provided October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intravenous injections provided from April 2, 2021, to April 30, 2021.

You asked the Plan to waive the copayments for intravenous injections. You say that you disagree with the facility charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

You received intravenous injections at an outpatient hospital facility, from April 2, 2021, to April 30, 2021, for a total of 5 services. Therefore, you are responsible to pay a $50 copayment per each visit. The total amount you owe is: $50 (copayment) x 5 (intravenous injections) = $250. 

You have been asked to pay the total copayment amount of $250 for intravenous injections. Intravenous injections fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 intravenous injections provided from April 2, 2021, to April 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a LifeVest rental provided from March 5, 2021, to March 16, 2021.

You asked the Plan to waive the coinsurance for a LifeVest rental. You say that you sent the LifeVest rental back less than two weeks after receiving it because it did not fit, and it bothered you while you slept. You also say you think you should not be responsible for this bill. 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 10% coinsurance for other Durable Medical Equipment (DME) equipment.

You have been asked to pay $293.15 in coinsurance, which is 10% of the allowed amount for a LifeVest rental ($2931.45 allowed amount x 10% coinsurance = $293.15). LifeVest rentals fall within the Durable Medical Equipment (DME) and Related 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 coinsurance for a LifeVest rental provided from March 5, 2021, to March 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 5, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON medical services. You say that you would like an exception to have the services processed as in-network until in-network status is obtained. The Plan denied your request. The Plan says the services were provided OON, and therefore are not covered.

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 medical services provided on March 5, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from February 2, 2021,
through February 24, 2021.

You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says prior
authorization was not obtained by the provider or facility.

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 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 physical therapy services provided from February 2, 2021,
through February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of impacted tooth (D7230) and the intravenous moderate sedation (D9239, D9243) provided on December 28, 2020.

You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says that these services are not covered by the 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 removal of impacted tooth (D7230) and the intravenous moderate sedation (D9239, D9243) provided on December 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy supplies provided from March 5, 2021 to March 26, 2021.
You asked the Plan to pay for the home infusion therapy supplies. 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.
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 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 the home infusion therapy supplies provided from March 5, 2021 to March 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto Tab.

You asked the Plan to pre-approve Entresto Tab. You say that you want to treat the enrollee with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.

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 Entresto Tab.

Benefits for Entresto Tab 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87798, 87486, 87541, 87581, 87640,
and 87633) provided on May 28, 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 a nursing facility
setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87798, 87486,
87541, 87581, 87640, and 87633) provided on May 28, 2020.