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

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on October 14, 2020.

You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow up visit after hip surgery and you should not have a 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 a $50 copayment for each specialist office visit. 

You have been asked to pay a $50 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 a specialist office visit provided on October 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from September 12, 2021, to September 14, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you had to stay in the hospital an extra day because the doctor misread your hemoglobin and hemocrit. You said that your copayment should be covered because of this. 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 $270 copayment per day for days 1-7 for inpatient hospital services.
Records show that you were in the hospital for two days. You were charged a copayment of $270 per day, for a total of $540. This copayment applies regardless of the reason for the length of your stay. 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 services you received from September 12, 2021, to September 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 24, 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 services are not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 36000 (introduction of needle or intracatheter, vein) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on March 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the computed tomography, of the abdomen; without contrast material, followed by contrast material (74170) and the low osmolar contrast material, 300-399 mg/ml iodine concentration (Q9967) provided on June 29, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan'sdenial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to theservices provided.
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 Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). Additionally, you must pay a 20% coinsurance for each Medicare-covered medical supply. Supplies for which an appropriate separate charge is made by providers such as, chemical agents used in certain diagnostic procedures are subject to cost sharing.
You have been asked to pay $100.69. This amount includes a $90 copayment for the Medicare-covered diagnostic radiology service provided. Additionally, this includes the Plan allowed amount of $53.46 x 20% coinsurance=$10.69 for the Medicare-covered medical supply provided. 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 cost share for the computed tomography, of the abdomen; without contrast material, followed by contrast material (74170) and the low osmolar contrast material, 300-399 mg/ml iodine concentration (Q9967) provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower leg platform crutch substitute (Roll-A-Bout).
You asked the Plan to pre-approve Roll-A-Bout crutch substitute. You say that you will be having ankle surgery so it will be hard for you to use a walker. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that there is insufficient literature to establish the medical necessity of a Roll-A-Bout crutch substitute product.
We looked at the file and Medicare rules. This item is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of Roll-A-Bout crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower leg platform crutch substitute (Roll-A-Bout).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on September 22, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. 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 out of network medical services provided to the enrollee on September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not
meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve continued SNF care. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found you do not have any parental
medications, complex wound care or nutrition given via a feeding tube. You received skilled care and
improved; however, your functional improvement had plateaued by February 26, 2022 and you did not require
any further inpatient skilled rehab services. Your function was at or near your prior level of function and you
could be discharged to a lower level of care for further services. As of February 26, 2022, you required
custodial services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 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 laboratory services provided on August 24, 2020 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport services provided on September 8, 2021.

You asked the Plan to pay for the ambulance transport services. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled non-urgent visit is not a Medicare covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. 

The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for ambulance transport services provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
August 1, 2021, to August 12, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should
be covered as you cannot afford to pay them. The Plan denied your request. The Plan says the cost-sharing
applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment per day for days 1-7 of Inpatient Hospital Care.
You have been asked to pay a $1,575 copayment for seven days of inpatient hospital 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 inpatient hospital services provided from August 1, 2021, to August
12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of torus mandibular (D7473) provided by a
participating provider on June 23, 2021.
You asked the Plan to pay for the removal of torus mandibular. You say that this surgery was medically
necessary to increase your quality of life. The Plan denied your request. The Plan says D7473 is not a covered
benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 torus mandibular (D7473) provided by a participating provider on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on September 28, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. 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 out of network medical services provided to the enrollee on September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
You asked the Plan to pre-approve a home mechanical ventilator. You say that that this device would help the
enrollee with her respiratory failure. The Plan denied your request. The Plan says that a home mechanical
ventilator being used in settings that a BiPAP could provide is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a home mechanical ventilator. Our
reviewer says that a home mechanical ventilator is not medically reasonable and necessary. This patient has
mild CO2 retention during acute illness that is likely multifactorial, including COPD, lung cancer, diastolic
heart failure, and possible radiation pneumonitis and/or pneumonia. Chronic CO2 retention has not been
confirmed on an arterial blood gas (ABG) done while stable as an outpatient. BiPAP at home has not been
tried. Medicare does not cover a ventilator when used as BiPAP. Our physician reviewer found that the
enrollee's condition does not meet Medicare criteria for a home mechanical ventilator.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a home mechanical ventilator have not been met. Therefore, we decided that the
Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on
October 27, 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 out of network medical services provided to the
enrollee on October 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventative procedure (COVID fee) (D1999) provided on December 1, 2021.

You asked the Plan to pay for the unspecified preventative procedure. You say that you were not told beforehand that you would owe this fee. The Plan denied your request. The Plan says this service is not covered by your supplemental dental benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 unspecified preventative procedure (COVID fee) (D1999) provided on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the magnetic resonance imaging (MRI) of the abdomen you had on April 29, 2021.

You asked the Plan to waive the cost sharing for the MRI. You say that you have never been charged a $75 copayment for an MRI before. 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 20% coinsurance up to $75 per day for diagnostic radiology services. 

You have been asked to pay $75 for the MRI. The MRI falls within the diagnostic radiology services benefit category. This cost sharing applies regardless of what you may have paid in the past for this 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 cost sharing for the magnetic resonance imaging (MRI) of the abdomen you had on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 29, 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 services are not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-home prothrombin time (PT)/international normalized ratio (INR) monitoring system and supplies to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an in-home PT/INR monitoring system and supplies to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available that can provide the requested in-home PT/INR monitoring system and supplies.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an in-home prothrombin time (PT)/international normalized ratio (INR) monitoring system and supplies to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic surgical services provided to the enrollee on April 12, 2021.
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 the denied code is considered inclusive to another 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 27245 is a column II code to column I code 27132. 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 orthopedic surgical services provided to the enrollee on April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on
October 1, 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 has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care and chiropractic services require prior authorization.

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 out of network medical services provided to the
enrollee on October 1, 2021.