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

We decided that the Plan does not have to waive the coinsurance for an X-ray provided on February 4, 2020.
You asked the Plan to waive the coinsurance for an X-ray. You say that you saw your primary care physician
and should not owe a copayment. 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 X-rays.
You have been asked to pay the allowed amount of $30.42, which is less than the $35 copayment for an X-ray.
An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for an X-ray provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the genetic testing provided on January 18, 2019.
You asked the Plan to waive the coinsurance for the genetic testing. You say that you were told that this service was covered by insurance. 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% of the Medicare-allowed amount for services in all settings for each in-network Medicare-covered genetic test. You have been asked to pay $774.60 which is 20% of the allowed amount for the genetic testing. The allowed amount was $3,873. ($3,873 x 20% = $774.60). The genetic testing falls within the of 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 coinsurance for the genetic testing provided on January 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive coinsurance for the infusion therapy provided on January 14,
2020.
You asked the Plan to waive coinsurance for the infusion therapy. You say that you do not have the financial
means of being able to pay the $6,670 charge. 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 Medicare-covered Part B chemotherapy drugs and other Part B drugs.
You have been asked to pay $6,700 which is less than 20% of the allowed amount for the infusion therapy. The
allowed amount is $34,450.20. ($34,450.20 x 20% = $6,890.04). The infusion therapy falls within the
"Medicare Part B prescription drugs" benefit category. The records show you were charged less than the
standard coinsurance amount because you met your maximum out-of-pocket amount. 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 coinsurance for the infusion therapy provided on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on February 5, 2020 by an out of network (OON) provider.You asked the Plan to pay for vision services. You say that you would like this claim paid for.The Plan denied your request. The Plan says prior authorization was not obtained.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 has network providers available who can provide 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 vision services provided on February 5, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health treatment.
You asked the Plan to pre-approve the inpatient mental health services. You say that the services are medically
necessary. The Plan denied your request. The Plan says the enrollee's needs can be met in an outpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 the inpatient mental health services.
Our reviewer says that inpatient level care is not medically necessary. Our physician reviewer found upon
review, the records provided for the admission of this enrollee does not meet criteria for acute inpatient mental
health treatment as she was not shown to be a danger to herself or others, no auditory or visual hallucinations.
She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors or any
acute threats of safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the inpatient mental health services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home INR monitoring materials (HCPCS G0249) provided
to the enrollee on January 20, 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 payment cannot be processed, as the services were billed earlier than 25 days.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
In this case, the CPT Code Manual definition of HCPCS code G0249 is "Provision of test materials and
equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation,
or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in
the home and reporting of test results to physician; testing not occurring more frequently than once a week;
testing materials, billing units of service include 4 tests."
We asked our coding 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 services. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found the documentation provided
for this appeal indicates that HCPCS code G0249 was submitted to the health plan for dates of services January
10, 2020 and for January 20, 2020. This is 10 days apart, which fails to meet the Medicare frequency
requirements, therefore this service is not eligible for reimbursement consideration.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for home INR monitoring materials (HCPCS G0249) provided to the enrollee on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940 x 4).
You asked the Plan to pre-approve these services. You say that chiropractic manipulative treatment is
medically necessary for the treatment of migraine headaches. The Plan denied your request. The Plan says the
chiropractic manipulative treatment requested is not medically necessary.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
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 these services. Our reviewer says that
the enrollee does not meet criteria for coverage of chiropractic manipulative treatment. Our physician reviewer
found that you have not submitted evidence of medical necessity for any chiropractic treatments. There is no
evidence of complete examination findings such as quantifiable measures of range of motion and strength,
orthopedic and neurological findings, palpation and postural findings or any evidence of any examination
findings to support chiropractic treatment. The submitted chart notes reveal no evidence of numerically valued
subjective complaints, significant findings or significant changes in findings to support chiropractic treatment.
There is no evidence that treatment cures or relieves the enrollee's complaints, that she has exhibited significant
subjective and objective improvement, that she has received any benefit from chiropractic treatment or that any
additional chiropractic treatments will significantly alter the outcome or result in resolution of the enrollee's
complaints. The only treatment allowed by Medicare for chiropractors is to treat a subluxation of the spine. The
subluxation may be demonstrated by x-ray or by physical examination. There are no submitted imaging studies
to reveal evidence of a subluxation. The chart notes provided do not reveal evidence of a subluxation of the
spine. Therefore, chiropractic treatments are medically unnecessary, exceed a reasonable prognosis and are not
supported by Medicare guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the chiropractic services have not been met. Therefore, we decided that the Plan
does not have to pre-approve chiropractic manipulative treatment (98940 x 4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair.You asked the Plan to pre-approve a seat lift chair. You say that the requested item is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.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 seat lift chair. Our reviewer says that the item is not medically necessary. Our physician reviewer found it is not clear from the provided records that a seat lift is included in the treating practitioner's course of treatment. It does not show that a seat lift is likely to affect improvement in the enrollee's condition or arrest or retard deterioration in the enrollee's condition. Also, the provided records do not show that the enrollee is completely incapable of standing from a chair in the home.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 seat lift chair have not been met.Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient mental health services
rendered from January 6, 2020 and January 20, 2020.
You asked the Plan to waive the copayments for these services. You say that you would like further
reimbursement. The Plan denied your request. The Plan says the copayments were applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for out-of-network outpatient mental health care in a specialist's office.
Review of the file shows that you received outpatient mental health services on January 6, 2020 and January
20, 2020. Based on your contract with the Plan, there is a $50 copayment for out-of-network outpatient mental
health care in a specialist's office. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. However, the Medicare allowed amount for these services was $28.43 per date of service.
Given that the allowed amount was less than the $50 copayment, you have been asked to pay $28.43 per date
of service for these services, for a total of $56.86.
The rules say that payment for codes with a status indicator of B is always bundled into payment for other
services not specified.
The file shows that the provider submitted a claim for procedure code 90885 (psychiatric evaluation of hospital
records) for January 20, 2020. This code has a status indicator of B and no separate Medicare payment. The
Plan cannot reimburse these services.
Therefore, we decided that the Plan does not have to waive the copayments for the outpatient mental health
services rendered from January 6, 2020 and January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation or provide additional payment for the periodic oral evaluation, prophylaxis and topical application of fluoride provided from February 18, 2020 to February 24, 2020.You asked the Plan to pay for the comprehensive oral evaluation and provide additional payment for the periodic oral evaluation, prophylaxis and topical application of fluoride. You say that you needed this treatment because you have issues chewing food and tooth pain.The Plan denied your request. The Plan says that the cost share was applied correctly.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. The Plan rules say you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider and that comprehensive exams are covered once every three plan year.We looked at the file, and Medicare rules. The file indicates the Plan paid for a comprehensive oral evaluation for the date of service November 28, 2020, which is less than three years ago. The file also indicates you went to an out-of-network provider and the plan paid up to the MAC for covered services. You are responsible for any charges over that amount.Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation or provide additional payment for the periodic oral evaluation, prophylaxis and topical application of fluoride provided from February 18, 2020 to February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup, tooth 15 (D2950).You asked the Plan to pre-approve the dental services. You say that you are appealing coverage for a full crown on tooth 15 in which root canal therapy has already been completed. Without a crown the possibility of fracture or eventual loss is significantly greater.The Plan denied your request. The Plan says this service is not covered under the plan 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 pre-approve core buildup, tooth 15 (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 10, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services are provided in good faith. The
Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's
primary care physician did not refer these services.
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 has network providers
available who can provide 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 physician services provided on December 10,
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 27, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 28, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 Plandid not pre-approve the laboratory 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 laboratory services provided on October 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery.You asked the Plan to pre-approve the battery. You say that the current battery won't last long in a power outage so you need a second battery.The Plan denied your request. The Plan says batteries are not eligible for coverage.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a backup battery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on September 18, 2019. You asked the Plan to pay for the core buildup. You say that a Plan representative stated that there is record of your telephone inquiry regarding the dental Plan and when you initiated the dental addition to your health plan. The Plan denied your request. The Plan says you were not eligible for this service until February 1, 2020, when your dental plan became effective.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The Plan contract states that the Plan offers an optional supplemental benefit that is not included in your benefits package, you must sign up for the optional supplemental benefit, and will have to pay an additional premium for it. The records show that you were not enrolled in the optional supplemental benefit until February 1, 2020. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required provided on September 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January
17, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were only transported a
mile and were told you would not owe more than $90. 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 $220
copayment for ambulance services.
You have been asked to pay a $220 copayment for ambulance services. Ambulance services fall within the
ambulance services benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services
provided on January 17, 2020.