Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on February 2, 2021.

You asked the Plan to waive the copayment for these services. You say that you are dissatisfied with the treatment from this provider. The Plan denied your request. The Plan says the copayment was 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 $35 copayment for in-network specialist's office services.

Review of the file shows that you received specialist services on February 2, 2021. You have been asked to pay a $35 copayment for these services. These services fall within the in-network specialist's office 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 specialist services rendered on February 2, 2021.

Your complaint about the physician 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 9, 2020.

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 38780 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 38780 is retroperitoneal transabdominal
lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure).

We find that CPT code 38780 is not supported in the medical record. Specifically, the operative report does not
include documentation of an extensive retroperitoneal transabdominal lymphadenectomy. 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 surgical services rendered on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for vision care and Medicare Part B drugs provided on October 9, 2020, and November 13, 2020.

You asked the Plan to waive the coinsurance for vision care and Medicare Part B drugs. You say that you met the MOOP amount and deductible prior to receiving the services 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 the MOOP amount for 2020 is $1,600. Your contract with the Plan also clearly says that you must pay 15% coinsurance for vision care. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.

You received vision care and Medicare Part B drugs on October 9, 2020, and November 13, 2020. The record shows that due to the reprocessing of claims, you did not meet the $1,600 MOOP amount prior to receiving the services. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.

Please note that the $1,600 MOOP amount was met with the processing of these claims. The total amount you owe is: $569.55. 

You have been asked to pay the total amount of $569.55 for vision care and Medicare Part B drugs. Vision care falls within the vision care benefit category. Medicare Part B drugs fall within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for vision care and Medicare Part B drugs provided on October 9, 2020, and November 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0425, A0427) provided on October 26, 2020.

You asked the Plan to pay for the ambulance service, advanced life support, emergency transport, level 1 (A0425, A0427). You say that the ambulance services were medically necessary as the enrollee could not have been transported safely by any other means. The Plan denied your request. The Plan says the ambulance services were not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 the ambulance service, advanced life support, emergency transport, level 1 (A0425, A0427). Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found that this enrollee does not meet criteria for medical necessity of emergency transport services given that he was in stable condition upon the paramedics arrival with no distressing signs on exam or vitals. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service, advanced life support, emergency transport, level 1 (A0425, A0427) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0425, A0427) provided on October 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on December 16, 2020.

You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport
(A0428, A0425). The Plan denied your request. The Plan says that there is no evidence that this member's life would have been endangered with the use of non-emergency transportation. There was no contraindication to other modes of transportation.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 the ambulance service, basic life support, non-emergency transport (A0428, A0425). Our reviewer says that the ambulance services were not medically reasonable or necessary. Our physician reviewer found the provided documentation does not support that other means of transport would have been contraindicated. The provided documentation does not support that the enrollee required expertise or special equipment during transport. The provided documentation does not support that the ambulance transport on December 16, 2020 was medically reasonable or necessary for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service, basic life support, non-emergency transport (A0428, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on December 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for dental services (D0120, D0220, D0230, D1110) provided January 27, 2021.

You asked the Plan to pay in full for the dental services. You say that your benefit includes out-of-network services and the dental services should be covered in full. The Plan denied your request. The Plan says the Evidence of Coverage explains that services obtained outside the plan's preferred dental network may cost more. Payment is limited to the allowable amount.

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, coverage for out-of-network services is limited to the maximum allowable amount. Any amount billed above the allowable amount is the enrollee's responsibility. The billed amount exceeds the maximum allowable amount, and the services were not obtained from an in-network dental provider. Therefore, we decided that the Plan does not have to pay in full for dental services (D0120, D0220, D0230, D1110) provided January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.

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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on January 11, 2021.

You asked the Plan to pay for glucose monitoring supplies. You say that this is supported in the records. The Plan denied your request. The Plan says a proof of delivery has not been submitted.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The submitted documentation does not include a delivery ticket or other proof of delivery documentation. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for glucose monitoring supplies (K0553) provided on January 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140), the pulp vitality test (D0460), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on December 22 ,2020.

You asked the Plan to pay the full amount for the dental services. You say that these services were pre-approved. You say that you did not know that it would be cancelled. You also say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that when you see an out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. The Plan says that pulp vitality test is not listed as a covered service. The Plan says that periapical x-rays are not listed as covered services either.

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 and limited oral evaluation is covered, you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist. Additionally, pulp vitality test and periapical x-rays are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the full amount for the limited oral evaluation (D0140), the pulp vitality test (D0460), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on December 22 ,2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from October 10, 2020, through October 12, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says from
October 10, 2020, through October 12, 2020, the Medicare coverage criteria has not been met.

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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that skilled services were not provided or medically necessary from October 10, 2020, through October 11, 2020. Skilled services were not provided on October 12, 2020, and reimbursement for such services cannot be sought, as the enrollee died on October 11, 2020. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from October 10, 2020, through October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 7, 2021.

You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness visit and you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for primary care provider visits. 

The medical records show that you received services beyond an annual wellness visit on January 7, 2021. Therefore, you are responsible to pay the $10 copayment.

You have been asked to pay a $10 copayment for an office visit. An office 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 for an office visit provided on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for esophagogastroduodenoscopy (43249) injection, propofol, 10 mg (J2704) catheter, balloon dilatation, non-vascular (C1726) provided on September 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the outpatient procedure. You say that it is your belief that documentation in the medical record supports this enrollee met indications for services that were performed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 esophagogastroduodenoscopy (43249) injection, propofol, 10 mg (J2704) catheter, balloon dilatation, non-vascular (C1726) provided on September 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on November 23, 2020.

You asked the Plan to pay for the consultation. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.

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 consultation (D9310) provided on November 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs, administered as outpatient services provided from July 12, 2019, through July 13, 2019.

You asked the Plan to waive the coinsurance for the prescription drugs. You say that you never received the medications during your admission and you were not informed about any copayment related to these medications. The Plan denied your request. The Plan says the claims were 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 Medicare Part B prescription drugs, administered as outpatient services from July 12, 2019, through July 13, 2019. You were asked to pay 20% coinsurance for the prescription drugs. Your 2019 EOC states that enrollees must pay 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs when provided at a hospital facility as an outpatient 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 coinsurance for Medicare Part B prescription drugs, administered as outpatient services provided from July 12, 2019, through July 13, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services described by current procedural terminology
(CPT) codes 87086 and 87186 provided on September 18, 2020.

You asked the Plan to pay for CPT codes 87086 and 87186. 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 were paid on another
claim.

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.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of CPT codes 87086 and 87186 have been met. Specifically, the file indicates that the services in
question were rendered by providers that are not part of the same group. This is not a duplicate claim.
Therefore, we decided that the Plan has to pay for the laboratory services described by current procedural
terminology (CPT) codes 87086 and 87186 provided on September 18, 2020.

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 drug testing coded 80307 and G0483 provided on November 10, 2020.

You asked the Plan to pay for the drug testing. 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 supported by the documentation.

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 80307 and G0483 are not supported in the medical record. Specifically, the submitted documentation did not contain sufficient detail to support the billed charges. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in an office place of service, place of service 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an outpatient rehabilitation setting place of service 57. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the periodic oral exam (D0120), the prophylaxis (D1110), bitewing x-rays (D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on February 24, 2021.

You asked the Plan to pay the in network rate for the dental services. You say that you have been seeing this dentist for 4 years. You say that you did not receive any notice he was not an approved in network provider. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network

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 and the services are listed as covered, dental services performed out of network may have a higher cost share. The record shows that the Plan paid the allowed amount for the services that were performed. Out of network dentists can bill you for additional costs if what they charge is more than the maximum payable benefit amount for preventive services covered by the plan. Therefore, we decided that the Plan does not have to pay the in network rate for the periodic oral exam (D0120), the prophylaxis (D1110), bitewing x-rays (D0274), the initial periapical x-ray (D0220), and the additional periapical x-ray (D0230) provided on February 24, 2021.