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

We decided that the Plan does not have to waive the copayment for the nuclear medicine study of vessels of heart using drugs or exercise (78452) provided February 10, 2021.
You asked the Plan to waive the copayment for the nuclear medicine study of vessels of heart using drugs or exercise. You say that you received incorrect information regarding your copayment. The Plan denied your request. The Plan says the claim processed correctly in this case.
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 $160 copayment for Medicare-covered radiological diagnostic services. You have been asked to pay a $160 copayment for the nuclear medicine study of vessels of heart using drugs or exercise. This service falls within the Medicare-covered radiological diagnostic 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 nuclear medicine study of vessels of heart using drugs or exercise (78452) provided February 10, 2021.
Your complaint about potentially receiving incorrect information from the Plan 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-ray (D0270), and resin-based composite (D2392) provided on December 29, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, bitewing x-ray, and resin-based composite. You say that you should not be held responsible for the bill you received. The Plan denied your request. The Plan says the total liability amount of $342.00 was applied correctly. The Plan also says that the enrollee liability is a contractual obligation under the Plan and cannot be waived.
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, you are responsible for the difference
between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for
the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), bitewing x-ray
(D0270), and resin-based composite (D2392) provided on December 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS) treatment for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says mild or moderate major depressive disorder is excluded from coverage.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's diagnosis is "major depression, recurrent, chronic." The clinical documentation does not support that the enrollee's major depressive disorder would be considered severe. The LCD requires a diagnosis of severe major depressive disorder. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve repetitive transcranial magnetic stimulation (rTMS) treatment for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 3, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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
services 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 services provided by an out-of-network provider on February
3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the methadone administration services rendered from October 1, 2019 to October 29, 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 claims were billed incorrectly.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. The provider billed the services at issue with code H0020 (methadone administration). This code has a status indicator of I and is not valid for Medicare purposes. The Plan has requested a corrected claim from the provider. Therefore, we decided that the Plan does not have to pay for the methadone administration services rendered from October 1, 2019 to October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the office visit provided on October 6, 2020.

You asked the Plan to waive the co-payment for the office visit. You say that the physician assistant said they refused to treat you and the charge is invalid. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 co-payment for each in-person specialist visit.

You have been asked to pay a $40 co-payment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show services were provided during the visit. 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 co-payment for the office visit provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer from the scalp, arm, and/or leg reported during a right shoulder procedure on December 22, 2020 billed with code 14020-RT.

You asked the Plan to pay for the surgical services as billed. You say that documentation supports that an "Adjacent tissue transfer/rearrangement, R shoulder, 3 x 3 cm" was done supporting code 14020. The Plan denied your request. The Plan says there is no evidence to support the billing of code 14020.

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 14020 is Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less.

We find that CPT code 14020 is not supported in the medical record. Specifically, there was no detailed operative note provided in the submitted records. Review of the documentation available does not reveal any mention of tissue transfer for any defect. Based on this information, we decided that Medicare rules for coverage of the surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer from the scalp, arm, and/or leg reported during a right shoulder procedure on December 22, 2020 billed with code 14020-RT.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of neurostimulator electrodes for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of why there can't be a trial first.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found neuromodulation therapy has no proven value for individuals with mechanical obstruction such as benign prostatic hypertrophy, or urethral stricture; persons with stress incontinence; and individuals with neurologic disease origins, such as multiple sclerosis, Parkinson's disease or diabetes with peripheral nerve involvement. The requested services have not been shown to be effective for urinary retention due to these causes. The medical records indicate that this individual has Parkinson's disease as the likely cause for her retention. As such, the requested services are not medically reasonable or necessary.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of neurostimulator electrodes for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged services rendered on February 4, 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 procedure code 99417 is not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.

We looked at the file and Medicare rules. Billed procedure code 99417 (prolonged services with or without direct patient contact) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the prolonged services rendered on February 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ultrasounds provided on January 25, 2021.
You asked the Plan to waive the coinsurance for the ultrasounds. You say that the copayment for diagnostic radiology services is too high compared to the cost of other services. You say that the copayment should be waived. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance up to $75 per day for Medicare-covered diagnostic radiology services. Diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan.
The enrollee has been asked to pay a total of $53.25 for the ultrasounds.
The ultrasounds fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ultrasounds provided on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 1, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you feel like the provider should have obtained prior authorization. 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 physician services provided on February 25, 2021 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 for the emergency department visit (99285) provided 01/15/2018.
You asked the Plan to waive the copayment for the emergency visit. You say that you do not agree with the copay of $80 because you were readmitted to the hospital within 24 hours. There should not be a copay under ER because you were inpatient from 01/15/2018 to 01/17/2018. The Plan denied your request. The Plan says this claim was processed with an $80 copay for emergency room services instead of the $400 copay for observation.
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 $400 copayment for all other outpatient services including observation and outpatient surgical services not provided in an ambulatory surgery center. You have been asked to pay $80 for the emergency visit. The plan reviewed your files and found that you were
charged less than your correct cost share for observation care. Since you were initially given the copayment amount of $80 for emergency care instead of $400 for observation, you are responsible for the lesser amount of $80. The emergency visit 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 for the emergency department visit (99285) provided 01/15/2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on January 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that the Plan denied these codes in error. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan.
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 office services provided on January 22, 2021 by
an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for group psychotherapy services (90853) provided October 14, 2020 to November 4, 2020.
You asked the Plan to waive the copayment for the psychotherapy services. You say that you did not know there would be a copay. You were advised by the provider there may not be a charge for any of the sessions. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $35 copayment per individual or group visit for outpatient mental health care. You have been asked to pay $280 ($35 x 8 visits) for the psychotherapy services. the psychotherapy services fall within the Outpatient mental health care 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 group psychotherapy services (90853) provided October 14, 2020 to November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for specialist services. You say that prior authorization was not obtained because services were required quickly. You would like this claim reprocessed and paid due to medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The 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 mitem/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 specialist services provided on January 8, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on March 22, 2021 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that these services were medically necessary. 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 a participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 wound care provided
on March 22, 2021 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording (93306) provided November 23, 2020.
You asked the Plan to waive the copayment for the diagnostic service. You say that you believe that the copayment should only be $40 for the visit The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $160 copayment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
You have been asked to pay $160 copayment for the diagnostic service. The diagnostic service 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, transthoracic, real-time with image documentation (2D), includes M-mode recording (93306) provided November 23, 2020.