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

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on August 23, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were anticipating a  preventive colonoscopy. You say that you expect a reasonable patient responsibility.The Plan denied your request. The Plan says the copayment 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 $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical centeror hospital outpatient facility.You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefitcategory. The records show that polyps were removed, which makes this a surgical 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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe colonoscopy provided on August 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and maxillary partial denture provided on September 23, 2019You asked the Plan to pay forthe periapical x-ray and maxillary partial denture. You say that had you know that your insurance was so inadequate you would have looked elsewhere.The Plan denied your request. The Plan says these procedures are not benefits under the dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and maxillary partial denture provided on September 23, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe air ambulance services provided to the enrollee on April 29, 2019.You asked the Plan to pay forthe air ambulance services. You say that emergent transport to a burn center was reasonable.The Plandenied your request. The Plan says that the member was enrolled in hospice on the date of service in question.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe air ambulance services provided to the enrollee on April 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit provided on August 21, 2019.You asked the Plan to pay forthe office visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 theitems/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 forthe office visit provided on August 21, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on July 22, 2019.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you were not told
that you would 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 $150
copayment for nuclear medicine.
You have been asked to pay a $150 copayment for myocardial perfusion imaging. Myocardial perfusion
imaging 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 copayment for myocardial perfusion imaging provided on July 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided
on August 20, 2019.
You asked the Plan to pay for the topical application of fluoride varnish. The Plan denied your request. The
Plan says the topical application of fluoride varnish is not listed as a covered service.
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 topical application of fluoride
varnish is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay
for the topical application of fluoride varnish (D1206) provided on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on August 23, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plansays the TC and PC are included in the facility payment.The Plan must follow Medicare rules. Medicare rules say that the PC for diagnostic services is payable when furnished in a different payment locality than the TC.We looked at the file and Medicare rules. The file shows that the PC and TC were performed in the same facility setting. Separate payment for the PC is not allowed.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on August 23, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe Positron emission tomography (PET) scan services provided on November 16, 2018.You asked the Plan to pay forthe PET scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the code billed has not met the associated diagnosis code relationship criteria.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered when medically necessary. Review of the file shows that the plan states that the LCA, A53132has a list of diagnosis codes that support medical necessity and any codes not present on that list, are not medically necessary. While the LCAdoes have a section fora list of diagnosis codes that supportmedical necessity, the LCAdoes not state that any code not listed is not medically necessary.In addition, the ICD-10 Codes that are Not Coveredsection only has one code listed that is not covered and the diagnosis code listed was not billed with the service.We looked at the file and Medicare rules.Based on this information, we decided that Medicare rules for coverage of the PET scan havebeen met.Therefore, we decided that the Plan has to pay forthe Positron emission tomography (PET) scan services provided on November 16, 2018.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible fora fine needle aspiration biopsy provided on August 13, 2019.You asked the Plan to waive the deductible fora fine needle aspiration biopsy. You say that you feel that you should only owe a specialist 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. Your contract with the Plan says that there is a $1,000 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a fine needle aspiration biopsy on August 13, 2019. The record shows that you had only paid $80.14 toward the $1,000 deductible. Therefore, you are responsible to pay the allowed amount of $676.00.The item or service you asked the Planto waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a fine needle aspiration biopsy was received on August 13, 2019.Therefore, we decided that the Plan does not have to waive the deductible fora fine needle aspiration biopsy provided on August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on April 24, 2019.You asked the Plan to pay forthe shingles vaccine. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine provided on April 24, 2019.Benefits for the shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 16, 2019 by out of network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 involvingemergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The referring provider 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 forthe medical services provided on September 16, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on July 9, 2019.You asked the Plan to pay fora shingles vaccine. You say that this should be covered.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicaredoes not pay for or provide a shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine.Therefore, we decided that the Plan does not have to pay fora Zoster (shingles) vaccine (90750) provided on July 9, 2019.Benefits for a shingles vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemethadone 10mg tablets.You asked the Planto pre-approvethe methadone tablets. You say that the enrollee has received pain relief from the use of this drug and it should be continued.The Plandenied your request. The Plansaysthis is an oral drug that must be covered by Part D. The request should be sent to the Part D plan.ThePlan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approvemethadone 10mg tablets.Benefits forthe methadone tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forwound debridement provided from July 8, 2019 to July 22, 2019.You asked the Plan to waive the copayment forwound debridement. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly saysthat you must pay a $175 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received wound debridement from July 8, 2019 to July 22, 2019 for a total of 3 visits. Wound debridementis considered an outpatient surgical procedure. Therefore, you are responsible to pay a $175 copayment per each service. The total amount you owe is: $175 (copayment) x 3 (services) = $525.00.You have been asked to pay the total copayment amount of $525.00 for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forwound debridement provided from July 8, 2019 to July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that an intensive rehab program is the best chance for the enrollee to make a good recovery.The Plandenied your request. The Plansaysthere are no acute medical needs and no needs for the intensity of IRF care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found The records indicate this enrollee has had functional decline since a hospital stay in October, 2019. The records indicate this member's recent history is significant for UTI status post IVF and IV antibiotics, and lung cancer status post left lobectomy and chemotherapy. This 84 year old member is now physically debilitated and warranting max assist for most/all aspects of care.Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the member is mostly maximal assist for functional transfers and ADL's and a less intensive, longer duration oftherapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the colonoscopy provided on August 12, 2019.You asked the Plan to reduce the copayment forthe colonoscopy. You say that you should be charged a $180 because you had your colonoscopy at an ambulatory surgical center. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record showsyou were billed by the hospital.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 thatthe Plan does not have to reduce the copayment forthe colonoscopy provided on August 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride (D1208), initial intraoral x-ray (D0220), and the additional intraoral x-ray (D0230) provided on August 5, 2019.You asked the Plan to pay forthe topical application of fluoride, and the intraoral x-rays. You say that a Plan representative advised that you had a PPO plan. You say that you never would have gone to your dentist had you known you would have to pay the full price.The Plan denied your request. The Plan says the intraoral x-rays are not listed as a covered service. The Plan also says that the topical application of fluoride is not listed as a covered service.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 topical application of fluoride, and intraoral x-rays are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe topical application of fluoride (D1208), initial intraoral x-ray (D0220), and the additional intraoral x-ray (D0230) provided on August 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forX-rays provided on July 1, 2019You asked the Plan to waive the deductible for X-rays. You say that you met the MOOP for the year and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible forout-of-network outpatient diagnostic tests and therapeutic services and supplies. You received an X-ray on July 1, 2019. The record shows that you had only paid $5,050.06 toward the $9,500 MOOP. The record also shows that you had only paid $672.20 toward the $750 deductible. Therefore, you are responsible to pay the allowed amount of $72.03. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time X-rays were received on July 1, 2019.Therefore, we decided that the Plan does not have to waive the deductible forX-rays provided on July 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and coinsurance for an office visit (99214), chemotherapy administration (96402) and Leuprolide acetate (J9217) provided on February 11, 2019.You asked the Plan to waive the copayment for the office visit, chemotherapy administration and Leuprolide acetate. You say that you should not be charged two different cost shares for a single point of contact with the provider. The Plan denied your request. The Plan says your copayment and coinsurance have been assessed 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 20% coinsurance and $30 copayment for Medicare Part B Prescription Drugs and Specialist Services. You have been asked to pay a $30 copayment for the specialist office visit. The correct copayment has been assessed. You have been asked to pay $274.09 for Leuprolide acetate. The allowed amount is $1,370.46. 20% of $1,370.46 is $274.09. You have been asked to pay the correct coinsurance. You have been asked to pay $6.51 for chemotherapy administration. The allowed amount is $32.56. 20% of $32.56 is $6.51. You have been asked to pay the correct coinsurance. You have been asked to pay a 20% coinsurance and $30 copayment for the office visit, chemotherapy administration and Leuprolide acetate. The office visit, chemotherapy administration and Leuprolide acetate fall within the Medicare Part B Prescription Drugs and Specialist Services benefit categories. 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 Plandoes not have to waive the copayment and coinsurance for an office visit (99214), chemotherapy administration (96402) and Leuprolide acetate (J9217) provided on February 11, 2019.