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

We decided that the Plan does not have to waive the copayment for the echocardiography provided on December 3, 2020.
You asked the Plan to waive the copayment for the echocardiography. You say that you want the copayment to be waived. 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 $10 per day for Medicare-covered tests. You have been asked to pay a $10 copayment for the echocardiography. The echocardiography 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 the echocardiography provided on December 3, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on January 19, 2021.
You asked the Plan to pay for lab tests. You say that you have a family history of cancer so needed this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. This testing was performed by an in-network provider. The file does not show that the Plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on January 19, 2021.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder x-ray provided on October 16, 2020 by an out of network provider.
You asked the Plan to pay for Radiologic examination, shoulder; complete, minimum of 2 views (73030). You say that the services were medically necessary. The Plan denied your request. The Plan says the out of network services were not urgent/emergent and not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. 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 the shoulder x-ray provided on October 16, 2020 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemodenervation provided on December 1, 2020.
You asked the Plan to waive the copayment for chemodenervation. You say that you cannot afford to be charged every time you need the service and worry that your health will suffer due to this. 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 outpatient surgery and other medical services provided at hospital outpatient facilities. You received chemodenervation at an outpatient hospital facility on December 1, 2020. Chemodenervation is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for chemodenervation. Chemodenervation falls within the outpatient surgery and other medical 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 for chemodenervation provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for amputation (CPT code 27886-80) provided to the enrollee on October 21, 2020, by a non-contracted provider, a licensed surgical assistant (LSA).
You asked the Plan to pay for the surgical services. You say that the primary surgeon requested services this assistant surgeon because they felt that it was in the best interest of the enrollee. The Plan denied your request. The Plan says services of an assistant surgeon, co-surgeon, or surgical team are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 27886-80. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for amputation (CPT code 27886-80) provided to the enrollee on October 21, 2020, by a non-contracted provider, a licensed surgical assistant (LSA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) received January 6, 2021.
You asked the Plan to pay for the crown. You say that you were not informed by the Plan that the requested service would not be covered. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 crown - porcelain/ceramic (D2740) received January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tissue exam provided by an out-of-network provider on
October 7, 2020.

You asked the Plan to pay for the tissue exam. You say that the provider and the patient would not know a
special authorization is necessary. You say that the specimens were received from an outside location and the
services should be considered for reimbursement. The Plan denied your request. The Plan says prior
authorization was required but 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the tissue exam provided by an out-of-network
provider on October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cleaning (D1110), periodic oral evaluation (D0120) and bitewing x-rays (D0274) provided on December 9, 2020.
You asked the Plan to pay for the dental services. You say that this was the same dentist you saw earlier in the year and your policy covers two cleanings. The Plan denied your request. The Plan says that you are enrolled in the Plan's mandatory supplemental benefit and did not choose to purchase additional dental coverage. Under the mandatory benefit, you are eligible for one cleaning and one periodic oral evaluation per calendar year. You previously had these services in June of 2020. The cleaning and evaluation provided in December 2020 exceeded the annual maximum of one cleaning and one periodic oral evaluation, therefore payment cannot be made for these services. In addition, this provider's network status changed in October of 2020 and they were out-of-network at the time of service. The x-rays you received require 50% coinsurance when received from an out-of-network provider. You may also be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. These claims were processed 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the periodic oral evaluation and cleaning are requested in a frequency not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cleaning (D1110) and periodic oral evaluation (D0120) provided on December 9, 2020.
You have been asked to pay $58.50 for the bitewing x-rays received from an out-of-network provider. The provider billed the Plan $75 for the x-rays. The Plan's maximum allowed charge for this bitewing procedure is $33. You are responsible for the difference between the maximum allowed fee and the amount the provider bills for the services ($75 - $33 = $42). You are also required to pay 50% coinsurance of the allowed amount for x-rays received out-of-network. ($33 x 50% = $16.50). ($42 + $16.50 = $58.50). This means 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 pay for or waive the cost-sharing for the bitewing x-rays (D0274) provided on December 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hip x-ray (CPT code 73502) provided on
January 13, 2021, at an in-network provider.
You asked the Plan to waive the copayment for the x-ray. You say that you should not have to pay for an x-ray.
The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC
benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received a hip x-ray (CPT Code 73502) on January 13, 2021, at an in-network
provider. You were asked to pay a $20 copayment for the x-ray. Your 2021 EOC says that enrollees must pay a
$20 copayment for each in-network x-ray service. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
hip x-ray (CPT code 73502) provided on January 13, 2021, at an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand finger orthosis provided on June 19, 2020 and the office visit and x-ray provided on September 11, 2020 by an out-of-network provider.
You asked the Plan to pay for the wrist hand finger orthosis, office visit and x-ray. You say that this doctor was your surgeon, and you were under his care from May until September. You say that additional approval shouldn't have been required. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wrist hand finger orthosis provided on June 19, 2020 and the office visit and x-ray provided on September 11, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the hand continuous passive motion device provided on January 7, 2020 and January 31, 2020.
You asked the Plan to reimburse you for the hand continuous passive motion device. You say that the Plan should reimburse you for 50% of the cost of the CPM. The Plan denied your request. The Plan says CPM devices for uses other than the knee are not covered.
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have received total knee replacement surgery. You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to reimburse you for the hand continuous passive motion device provided on January 7, 2020 and January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 15, 2021, by an OON
provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid.
The Plan denied your request. The Plan says there are in-network providers available for 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 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 physician services provided on January 15, 2021,
by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered on May 15, 2019 to May 18, 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 the records do not support the billed DRG and diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 025 and diagnosis code G93.6 (cerebral edema). 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 pay for these services. Our reviewer says that the records do not support the billed DRG and diagnosis code. Our physician reviewer found the enrollee was admitted to the hospital for treatment and biopsy of a cerebellar mass related to metastatic breast cancer. A computed tomography (CT) scan of the head revealed vasogenic edema associated with enhancing intracranial lesions, but no midline shift, mass effect, or impending herniation or hemispheric swelling or effacement of ventricles/sulci was noted. Based on the imaging findings being inconsistent with the cerebral edema definition, the DRG 025/G93.6 coding appears inappropriate and the provided records do not sufficiently support these codes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered on May 15, 2019 to May 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab services provided on October 22, 2020, by an
OON provider.
You asked the Plan to pay for outpatient lab services. You say that you would like this claim reprocessed and
paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's
primary care physician.
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 outpatient lab services provided on October 22,
2020, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for after-cataract laser surgery provided on September 10, 2020.

You asked the Plan to waive the copayment for the after-cataract laser surgery. You say that your husband had the same procedure two times at the same facility and his share of the cost was different. You say that the procedure took place at the surgery center but had nothing to do with actual surgery. 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 $395 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. 

You have been asked to pay $171.57, which is less than the standard $395 copayment for the after-cataract laser surgery. The after-cataract laser surgery falls within the "Outpatient Surgery and Other Medical 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 for after-cataract laser surgery provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the methylprednisolone acetate provided on July 11, 2019.
You asked the Plan to pay for Injection, methylprednisolone acetate, 40 mg. You say that the Plan should pay
this claim. The Plan denied your request. The Plan says the submitted documentation indicates a total of 120
mg was administered, supporting only 3 units.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.
We find that 4 units of CPT code J1030 are not supported in the medical record. The medical record only
supports 3 units of CPT code J1030. Based on this information, we decided that Medicare rules for coverage of
Injection, methylprednisolone acetate, 40 mg have not been met. Therefore, we decided that the Plan does not
have to pay for the methylprednisolone acetate provided on July 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT angiography provided on December 15, 2020.
You asked the Plan to waive the copayment for the CT angiography. You say that the CT scan was to monitor your health and see if you're a candidate for open heart surgery. You say that the copayment should be waived. 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 $250 per day for Medicare-covered diagnostic radiology services. You have been asked to pay a $250 copayment for the CT angiography. The CT angiography 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 the CT angiography provided on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 13, 2021.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you believe these services should be covered. The Plan denied your request. The Plan says these services exceed the frequency limitations in your benefit 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, comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) on October 15, 2019 and your comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 13, 2021.