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

We decided that the Plan does not have to waive the deductible for laboratory services provided on December 14, 2020.
You asked the Plan to waive the deductible for laboratory services. You say that you were not aware of the deductible. You say that the cost should be waived because the labs were for your physical. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $250. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $250 deductible applies to diagnostic laboratory tests. This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received on December 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on December 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the low dose CT scan for lung cancer screening (G0297) provided June 1, 2018.
You asked the Plan to pay for the diagnostic services. You say that you have received multiple calls from collection agency for an unpaid lung screening in the amount over $700. The Plan denied your request. The Plan says this claim was already processed and paid to the provider on December 11, 2018.
The Plan must follow Medicare rules. Medicare rules say that Claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the low dose CT scan for lung cancer screening (G0297) provided June 1, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on August 24, 2019.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was billed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the anesthesia services was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on August 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames, eyeglass lenses, and eyeglass lens coatings provided on March 9, 2020. You asked the Plan to pay for the eyeglass frames, eyeglass lenses, and eyeglass lens coatings. You say that you are entitled to $350 towards the purchase of either glasses or contact lenses. You say that you tried contact lenses but decided that you would rather purchase eyeglasses. You say that you never purchased the contact lenses and feel that you should still be entitled to use her eyewear benefit towards glasses. The Plan denied your request. The Plan says your remaining allowance for eyewear is only available for purchase of contact lenses. 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 either eyeglass or contact lens services per year, up to a maximum of $350. We looked at the file and the Plan's rules. The records show that the Plan was billed for a contact lens fitting provided on February 15, 2020. This utilized $75 of the yearly eyewear benefit. Because the Plan has paid for services related to contact lenses in the 2021 calendar year, and because the eyewear benefit is limited to coverage for either glasses or contact lenses, your remaining eyewear benefit allowance is only able to be used toward the cost of further contact lens services. Based on this information, we decided that the Plan's rules for coverage of the eyeglass frames, eyeglass lenses, and eyeglass lens coatings have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames, eyeglass lenses, and eyeglass lens coatings provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two pontics and three retainer crowns provided on September 14, 2020.
You asked the Plan to pay for the pontics and retainer crowns. You say that you were advised that you had the same coverage under this plan as your previous plan. The Plan denied your request. The Plan says these services are not covered. The Plan also says that in September of 2019, you were mailed the 2020 Annual Notice of Changes (ANOC) which serves to provide understanding for the upcoming year's benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two pontics and three retainer crowns provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided on October 19, 2020.
You asked the Plan to pay for the dental services. You say that a plan representative always reported that you receive 3 cleanings per year and 2 fluoride. You say that under this instruction, you booked this cleaning before your crown work to follow that same morning. You also say that under this situation, it is only fair that you pay this bill. The Plan denied your request. The Plan says 2 cleanings and 2 fluoride applications are covered per plan year. The Plan also says that the frequency limit for these services have been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 2 cleanings and 2 fluoride applications have been exceeded. The record shows that the Plan paid for these services that you received on February 17, 2020, and June 17, 2020. Additionally, the record does not show that you contacted customer service to confirm benefits or limitations prior to receiving the services. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and topical application of fluoride varnish (D1206) provided on October 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after March 19, 2021.
You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 coverage. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications. You had stable vital signs. You required contact guard assistance to minimal assistance with functional mobility including walking to 380 feet. The documentation does not support that you require the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that you require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage after March 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on December 13, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $325 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay $273.14 which is less than your copayment amount of $325 for an MRI. The correct copayment has been applied to the services that were provided. An MRI falls within the outpatient diagnostic tests/diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on December 13, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the vision services provided on December 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered by an out-of-network provider.
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 rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has confirmed that the provider was in-network with the Plan in 2018 and 2019. The Plan stated they paid for the services provided by this provider in 2018 and 2019. The file does not show that you were provided any information to inform you that this same provider is now out-of-network for the 2020 benefit year. Therefore, we decided that the Plan has to pay for the vision services provided on December 7, 2020 by an out of network (OON) provider.
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 pay for physician's services that you provided on April 28, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the service was received from an out of network provider. The member does not have out of network benefits.
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 physician's 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 physician's services that you provided on April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital services.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the inpatient level of care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 services are not medically necessary. Our physician reviewer found the enrollee is approved for an elective total hip arthroplasty (THA). He has a medication list suggestive of a cardiac history; however, there is no indication for high risk of a cardiovascular event or complications with the surgery. The inpatient level of care is not reasonable or medically necessary for the planned surgery. There is no expectation that the enrollee will require at least two midnights of care following the THA. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve acute inpatient hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services provided on October 12, 2020, and October 19, 2020.
You asked the Plan to waive the copayments for laboratory services. You say that you feel that the claims were not processed correctly and you should owe a $0 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 $20 copayment for laboratory services provided at a freestanding laboratory. You received laboratory services on October 12, 2020. Therefore, you are responsible to pay the $3 copayment. You received laboratory services on October 19, 2020. Therefore, you are responsible to pay the $3 copayment. The total amount you owe is: $6. You have been asked to pay the total copayment amount of $6 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 copayments for laboratory services provided on October 12, 2020, and October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the percutaneous transluminal revascularization procedure you had at an outpatient hospital facility from September 17, 2020, to September 18, 2020.
You asked the Plan to waive the copayment for the outpatient surgical procedure. You say that you were told there was no copayment for this surgery. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they have no phone records showing you were told this procedure would not have a copayment.
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 $325 copayment for outpatient surgery services. You have been asked to pay a $325 copayment for the outpatient surgical procedure. The outpatient surgical procedure falls within the outpatient surgery services benefit category. This copayment applies regardless of the reason for the procedure. 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 percutaneous transluminal revascularization procedure you had at an outpatient hospital facility from September 17, 2020, to September 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) services coded 70544 and 70549 provided on August 16, 2020.
You asked the Plan to pay for the MRA services. 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. We find that CPT codes 70544 and 70549 are not supported in the medical record. Specifically, an MRA was billed on the same date of service by the same provider. The documentation does not support the services as distinct as both were performed at the same time. Therefore, code 70544 cannot be verified. In addition, the documentation shows that code 70549 was a duplicate service billed by the same provider for the same date of service. The documentation does not support that the service being performed by the rendering provider on the date of service of August 16, 2020. Based on this information, we decided that Medicare rules for coverage of the MRA services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) services coded 70544 and 70549 provided on August 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for exercise equipment (A9300) received on September 21, 2020.
You asked the Plan to pay for exercise equipment. You say that the requested item will help you with constant pain in your back and legs and hips. The Plan denied your request. The Plan says rules for payment have not been met because the requested item does not qualify as durable medical equipment.
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 pay for exercise equipment (A9300) received on September 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a folding, wheeled walker provided on September 18, 2020.
You asked the Plan to pay for the folding, wheeled walker. The Plan denied your request. The Plan says that the services were not referred by a network provider or rendered in a participating facility. 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 folding, wheeled walker. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a folding, wheeled walker provided on September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services (A0431-QL, A0436-QL) provided on October 30, 2020.
You asked the Plan to pay for air ambulance services. You say that this was billed with the required QL modifier. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report the A0428 (BLS) HCPCS code, modifier QL, and modifier QM or QN. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Specifically, codes A0431 and A0436 are not the appropriate codes for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Therefore, we decided that the Plan does not have to pay for air ambulance services (A0431-QL, A0436-QL) provided on October 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement (11042).

You asked the Plan to pay for debridement. You say that this was medically necessary. The Plan denied your request. The Plan says this is bundled into another procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11042 has a Column One/Column Two relationship with code 28010 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for debridement (11042).