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

We decided that the Plan does not have to waive the copayment for the ultrasound measurement of bladder capacity provided on November 6, 2019.You asked the Plan to waive the copayment for the ultrasound measurement of bladder capacity. 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 (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for diagnostic procedures and tests provided in a specialist's office. You have been asked to pay the allowed amount of $13.16, which is less than the $30 copayment for the ultrasound measurement of bladder capacity. The ultrasound measurement of bladder capacity falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you havebeen 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 ultrasound measurement of bladder capacity provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 24, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 servicesat 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 physician's services provided on June 24,2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from November 1, 2019 to November 15, 2019.You asked the Plan to waive the copayment forthe SNF stay. You say that you were told you would not have any cost share to pay. 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 $0 copayment for each day for days 1-20 of a covered stay during a benefit period. You spay $156 each day for days 21-100 of a covered stay during a benefit period. You have been asked to pay a $936 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care (PA)" benefit category. See chart below.Dates of ServiceServiceCopayment per DaySNF DaysNumber of DaysMember LiabilityOctober 20, 2019 to October 31, 2019SNF stay$01-1212$0November 1, 2019 to November 8, 2019SNF stay$013-208$0November 9, 2019 to November 15. 2019SNF stay$15621-266$936Total$936 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 towaive the copayment forthe SNF stay provided from November 1, 2019 to November 15, 2019.Your complaint about the facility conducting themselves improperly is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PILD (0275T).You asked the Plan to pre-approve the PILD. You say that the coverage criteria needed to obtain authorization have been met. The Plandenied your request. The Plan says no evidence has been submitted to support that the enrollee is enrolled in the required clinical study.The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PILD have not been met. Specifically, the record does not indicate that the member is enrolled in an approved clinical study. Therefore, we decided that the Plan does not have to pre-approve PILD (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
You asked the Plan to pay for Power operated vehicle, group 1 standard. You say that it appears this can be resolved with passing the correct information on to the provider with the proper instructions. You would like to appeal until this can be corrected. The Plan denied your request. The Plan says this request does not meet the CMS LCD specific coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of Power operated vehicle, group 1 standard, have not been met. Therefore, we decided that the Plan does not have to pay for Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office services. You say that you are requesting approval based on an established plan of care. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on September 24, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you saw your primary care provider 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist visit. You had an office visit with a specialist on September 24, 2019. The record shows that the provider is not listed as your primary care physician. Therefore, you are responsible to pay the $40 specialist copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on July 1, 2019 and billed under codes 84315, G0481 and 82565.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the records provided do not support the services billed. The Plan states the medical records do not include definitive laboratory results for 8-14 drug classes to support the coding criteria for code G0481. The Plan states that specimen validity checks are built into the drug testing process, allowing for a basic determination of potential urine sample tampering. The Plan states that urine validity testing is considered a quality provided and is not separately reimbursable. The Plan also states the records do not contain results for codes 82565 and 84315 to support the coding criteria.
Medicare has specific coverage criteria for drug testing. In this case, there were insufficient records provided to show the enrollee met the required criteria for this testing at the time of service. This testing is not covered for screening purposes and when multiple tests are done at one time. Medicare coverage criteria were not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on July 1, 2019 and billed under codes 84315, G0481 and 82565.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayments for the outpatient services you received from
November 25, 2019, to November 28, 2019.
You asked the Plan to adjust the copayment. You say that you should not have to pay more than $210. The Plan
denied your request. The Plan says you are responsible for the cost share.
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 $200
copayment for each diagnostic radiology service and a $210 copayment for each outpatient stay at a hospital
facility.
Review of the file shows that you were provided outpatient services from November 25, 2019, to November
28, 2019. The services fall within the outpatient hospital 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 adjust the copayments for the outpatient services you received from November 25, 2019, to November 28,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post core. You asked the Plan to pre-approve a prefabricated post core. You say that these services are medically necessary. The Plan denied your request. The Plan says that this is not a covered benefit. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a prefabricated post core.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473).You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on November 25, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you would like this appeal reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was 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 an x-ray provided on November 25, 2019 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 99121) you received on September 11, 2019.You asked the Plan to pay for the services. You say that this should be covered.The Plan denied your request. The Plan says this is not a covered services from a chiropractor.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. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (CPT 99121) you received on September 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided by October 29, 2019.You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you had breast cancer 20 years ago and feel that mammograms should be fully covered.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 $10 copayment for each basic imaging service.The medical records show that you have a personal history of breast cancer. Therefore, the mammogram provided on October 29 2019 is considered diagnostic, not preventative, and you are responsible to pay the $10 copayment.  You have been asked to pay a $10 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided by October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the surgical supplies provided on May 24, 2019. You asked the Plan to waive the coinsurance for the surgical supplies. You say that you had no idea that your plan had a coinsurance. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 surgical supplies provided on May 24, 2019. You are asked to pay
20% coinsurance for the surgical supplies. 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 surgical supplies provided on May 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October 2,
2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you disagree on how this was
billed. 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 $300
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.
You have been asked to pay a $300 copayment for the ambulance ride. The ambulance ride falls 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 the
ambulance ride provided on October 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision services rendered to the enrollee on November 8, 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 submitted records do not support the billing of code 21554.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 21554 is excision, tumor, soft tissue of neck or anterior thorax, subfascial (e.g., intramuscular); 5 cm or greater. 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 submitted records do not support the billing of code 21554. Our physician reviewer found the submitted medical records do not include a pathology report confirming the size of the tumor; therefore, the billing of code 21554 is not supported. 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 pay for the excision services rendered to the enrollee on November 8, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided on June 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that Medicare does not
recognize this type of provider.
The Plan must follow Medicare rules. Medicare rules say that the services of a nurse practitioner (NP) may be
covered under Part B when all of the above conditions are met. 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.
We looked at the file and Medicare rules. The code in question is a payable code for physician services. There
is no evidence that the provider does not meet the definition of an NP and she has a valid NPI number. No
evidence is provided to show that the services were provided outside the scope of the NP's State license. The
progress note shows that the physician is collaborating with this provider and these are not statutorily
excluded services. The Plan has not provided any evidence to support that this provider cannot be paid for the
services at issue. Based on this information, we decided that Medicare rules for coverage of the services have
been met. Therefore, we decided that the Plan has to pay for the services provided on June 27, 2019.
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 pay for the medical services provided on September 6, 2019 to the enrollee by a non-network provider. 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 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 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 the medical services provided on September 6, 2019 to the enrollee by a non-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on September 13, 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 procedure code 29828 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 29828 is arthroscopy, shoulder, surgical; biceps tenodesis. We find that CPT code 29828 is not supported in the medical record. Specifically, the operative report does not include documentation of a surgical shoulder arthroscopy with biceps tenodesis. 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 services rendered to D. Kirby on September 13, 2019.