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

We decided that the Plan does not have to pay for the laboratory services provided on July 17, 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.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided from June 8, 2021, to June 18, 2021.
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that the enrollee could not be discharged until you found a facility to have them transferred to. You state that you were told that the stay would be covered by the plan. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for days 1-5 for inpatient mental health care.
The enrollee had an inpatient mental health stay from June 8, 2021, to June 18, 2021. Therefore, the enrollee is responsible to pay a $275 copayment for days 1-5 (June 8, 2021, to June 12, 2021). The total amount the enrollee owes is: $275 (copayment) x 5 (inpatient days) = $1,375. The enrollee has been asked to pay the total copayment amount of $1,375 for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient mental health care benefit category. 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 an inpatient mental health stay provided from June 8, 2021, to June 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on March 9, 2021.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on March 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally received on August 10, 2021.

You asked the Plan to pay for the 2D oral/facial photographic image obtained intra-orally or extra-orally. You say that you really needed this service. The Plan denied your request. The Plan says the service received 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 2D oral/facial photographic image obtained intra-orally or extra-orally received on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on May 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 laboratory testing provided on May 24, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 12, 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.

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 physician services provided to the enrollee on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from February 4, 2021, to February 8, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are really unhappy with the Plan and their lack of clarity and guidance in covering your kidney disease care. 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 $250 copayment for days 1-7 for inpatient hospital care. 

You had an inpatient hospital stay from February 4, 2021, to February 8, 2021. Therefore, you are responsible to pay a $250 copayment for days 1-4 (February 4, 2021, to February 7, 2021). The total amount you owe is: $250 (copayment) x 4 (inpatient days) = $1,000.

You have been asked to pay the total copayment amount of $1,000 for an inpatient hospital stay. An inpatient hospital stay falls 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 an inpatient hospital stay provided from February 4, 2021, to February 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the hospital observation services you received on June 15, 2021.
You asked the Plan to reduce the copayment for the hospital observation services. You say that you went to the hospital because of a low hemoglobin court. You stated that your copayment should have been $75, not $125. You stated that you had to go to the hospital before in 2019 and your copayment was $75. 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 $125 copayment for outpatient hospital observation services. You have been asked to pay a $125 copayment for the hospital observation services. The records show that this was not an emergency room visit. Rather, the records show that you received hospital observation services. In addition, you signed a Medicare Outpatient Observation Notice on June 15, 2021, in which you acknowledged that you were receiving hospital observation 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 reduce the copayment for the hospital observation services you received on June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration coded 99602 provided on April 19, 2021.

You asked the Plan to pay for the home infusion/specialty drug administration. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the CPT Code Manual definition of code 99602 is home infusion/specialty drug administration, per visit (up to 2 hours).

We find that CPT code 99602 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration coded 99602 provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of a refractive state (92015) provided on June 11, 2021, through September 11, 2021.
You asked the Plan to pay for the determination of a refractive state. You say that you would like reconsideration because your doctor wrote a prescription for eyeglasses and you do not believe you should be billed for this service.
The Plan denied your request. The Plan says no coverage for this treatment is owed under the terms, conditions, limitations, and exclusions contained in your contract.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services as part of a routine eye exam. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the determination of a refractive state have not been met. Specifically, the record indicates that you received a medical eye exam. The determination of a refractive state is not covered as part of a Medicare covered medical eye exam. Therefore, we decided that the Plan does not have to pay for the determination of a refractive state (92015) provided on June 11, 2021, through September 11, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the emergency room services provided July 29, 2020.
You asked the Plan to pay for the emergency room services. You say that you believe these services should be covered based on medical necessity. The Plan denied your request. The Plan says that the copayment has processed correctly in this case.
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 does not say in clear and accurate terms how much you should expect to pay for emergency room services. We looked at your contract with the Plan. The Plan contract does not clearly say how much enrollees must pay for emergency care services. Specifically, the contract reads that there is a $0 copayment - $90 copayment for each emergency room visit. There is no indication in the Plan's contract whether the copayment is either $0 or $90 and what circumstances dictate this copayment. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to pay for the emergency room services provided July 29, 2020.
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 waive the deductible for the out-of-network cardiology visit you had on February 5, 2021.
You asked the Plan to waive the deductible for the out-of-network cardiology visit. You say that you believe you had met your deductible. The Plan denied your request. The Plan says you were charged this deductible correctly. As of the February 5, 2021 date of service, you had only met $67.08 towards your deductible. You were assessed the remaining $135.92 towards your deductible with the out-of-network cardiology services on February 5, 2021.
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 $203 deductible which applies to medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $203 deductible which applies to the medical services you received. This cost sharing is a contractual obligation that had not been met at the time the out-of-network cardiology visit was received on February 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the out-of-network cardiology visit you had on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient cystoscopy and left
ureteroscopy procedure with laser lithotripsy and left ureteral stent removal you had at an outpatient hospital
facility on May 14, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you had to return to the
hospital because you had an infection from services you received on May 4, 2021. You said there should be no
copayment for this service. 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 $175
copayment per visit for outpatient surgery.
You have been asked to pay a $175 copayment per visit for the outpatient surgery. This copayment applies for
each visit, regardless of the reason for the surgery 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 cystoscopy and left ureteroscopy procedure with laser lithotripsy and left ureteral stent removal
you had at an outpatient hospital facility on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on May 14, 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 services provided to the enrollee on May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided by a provider who has opted out of the Medicare program provided on April 13, 2021.
You asked the Plan to pay for the dental 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 when provided by a provider who has opted out of the Medicare program.
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 the dental services provided by a provider who has opted out of the Medicare program provided on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim.
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 30, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you have never been charged $40 for laboratory services in the past. You state that the most you ever paid was $5. 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 $0 copayment for laboratory services provided in a primary care providers office, specialists office, or freestanding laboratory and a $40 copayment when provided at an urgent care or outpatient hospital facility. The record shows that you received laboratory services at an outpatient hospital facility on July 30, 2021. Therefore, you are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall 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 laboratory services provided on July 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical trays (A4550) and the syringe (A4657) provided on May 20, 2021.

You asked the Plan to pay for codes A4550 and A4657. 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. Code A4550 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Code A4657 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes. Therefore, we decided that the Plan does not have to pay for the surgical trays (A4550) and the syringe (A4657) provided on May 20, 2021.