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

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 24, 2020.

You asked the Plan to waive the copayment for the ER visit. You say that you only needed a COVID test but were sent home. You say that the benefit should be $25. 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 $120 copayment for emergency services in an emergency room. 

You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you were treated in the ER. 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 ER visit provided on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on November 25, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says this provider is not a network provider 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 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 laboratory services provided by an out-of-network provider on November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an Influenza virus vaccine and administration provided on
September 20, 2020.

You asked the Plan to pay for the Influenza virus vaccine and administration. The Plan denied your request.
The Plan says you must receive your care from a network provider. In most cases, care you receive from an
out-of-network provider will not be covered. If you need medical care that Medicare requires our Plan to cover
and the providers in our network cannot provide this care, you can get this care from an out-of-network
provider. You, or your PCP, must obtain authorization from the Plan prior to seeking care.

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
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 an Influenza virus vaccine and administration provided on
September 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (69210, 99213) provided on November 11, 2020 to November 18, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent.

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 physician services (69210, 99213) provided on November 11, 2020 to November 18, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea CardioMEMS device.You asked the Plan to pre-approvethe CardioMEMS device. You say that you would like reconsideration because this device is medically necessary for the member's worsening heart failure.The Plan denied your request. The Plan says that the member is not part of a category B IDE study.The Plan must follow Medicare rules. Medicare rulessay that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the member has un-revascularizable coronary artery disease and the repeated recent and short spaced congestive heart failure, hospitalizations despite ongoing aggressive medical therapy to manage his congestive heart failure.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 CardioMEMS device have been met.Therefore, we decided that the Plan has to pre-approvea CardioMEMS device.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 a positron emission tomography (PET) scan (78815) provided on October 28, 2020.

You asked the Plan to pay for a PET scan. You say that this was billed correctly. The Plan denied your request. The Plan says the billed diagnosis is not appropriate.

The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate diagnosis code. 

We looked at the file and Medicare rules. The billed diagnosis code, C34.91, is not listed as an appropriate code. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815) provided on October 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) scan of the brain stem (70553) provided on October 23, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $325 per day for Medicare-covered diagnostic radiology services. 

You have been asked to pay a $325 copayment for the Medicare-covered diagnostic radiology service provided. 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 magnetic resonance imaging (MRI) scan of the brain stem (70553) provided on October 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 11, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because there was no other option for the enrollee. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for ambulance services. 

The enrollee has been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services 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 copayment for ambulance services provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to adjust the cost sharing for the demonstration and provision of test materials and equipment for home INR monitoring (G0428, G0429) provided from March 24, 2020, through December 22, 2020.

You asked the Plan to adjust the cost sharing. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the physician specialist services provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a 20% coinsurance for each Medicare-covered durable medical equipment and related supplies. The Plan says you must pay $330 ($30 copayment x 11 days) for the physician specialist services provided. Based on the Plan contract, however, you cannot be billed more than 20% of the approved amount for the medical supplies provided. It is not reasonable to consider the services described by these codes as physician specialist services. The codes describe the demonstration and provision of testing supplies and are billed for the date that the supplies are delivered. As such, we find that the most accurate cost sharing category for this is durable medical equipment. Therefore, we decided that the Plan has to adjust the cost sharing for the demonstration and provision of test materials and equipment for home INR monitoring (G0428, G0429) provided from March 24, 2020, through December 22, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on August 6, 2020.

You asked the Plan to pay for the orthoses. 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 payable.

The Plan must follow Medicare rules. The rules state that durable medical equipment is only covered under certain indications.

Review of the file shows that the Plan has attested that the enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. The documentation does not support an established relationship between the enrollee and the ordering physician. This means that no payment may be made for this item.Therefore, we decided that the Plan does not have to pay for  the orthoses provided on August 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography (CT) image (D0364, D1999) provided on November 17, 2020.

You asked the Plan to pay for a cone beam CT image. You say that you needed the service done to determine the treatment for your tooth. The Plan denied your request. The Plan says the service 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 pay for a cone beam computed tomography (CT) image (D0364, D1999) provided on November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on November 20, 2020, November 27, 2020, and December 11, 2020 by an out of network provider.

You asked the Plan to pay for the chiropractic services. You say that the provider is in network. The Plan denied your request. The Plan says the provider is out-of-network and was 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 chiropractic services provided on November 20, 2020, November 27, 2020, and December 11, 2020 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for after cataract laser surgery provided on September 2, 2020 by an out of network provider.

You asked the Plan to pay for after cataract laser surgery (66821). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider and facility are non-Medicare certified.

Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say no Medicare payment may be made to for services provided directly by a provider who is not eligible to take Medicare payment. 

The requested provider in this case is not a certified Medicare provider. The service at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided that the Plan does not have to pay for after cataract laser surgery provided on September 2, 2020 by a non-Medicare certified provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture with interpretation (D0364) provided on December 23, 2020.

You asked the Plan to pay for the dental service. You say that these services are necessary. You say that you are disabled. You say that your health is greatly compromised. You also say that you have all dental services are medically necessary due to the implanted morphine pump compromising your general health. The Plan denied your request. The Plan says cone beam CT capture with interpretation is not listed as a covered service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the 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 cone beam CT capture with interpretation (D0364) provided on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings for teeth # 10, 11, and 22 provided on November
16, 2020.

You asked the Plan to pay for the dental services. You say that you had pre-authorization that said your portion
of the claim would be $305 before making your appointment. You also say that you were told the plan would
cover what was authorized. You also say that you would not have made the appointment if you knew it was
going to cost you over $400. The Plan denied your request. The Plan says 2 fillings are covered per calendar
year. The Plan says that covered fillings have a 50% coinsurance when they are performed in network. The
Plan also says that the frequency limit for fillings has been exceeded.

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 fillings are a covered service, the
frequency limit has been exceeded. The record shows that the Plan paid for the fillings for teeth # 10 and 22.
Additionally, the covered fillings have a 50% coinsurance. This is a contractual obligation you agreed to when
you enrolled in the Plan's dental coverage.

CPT Code Billed Allowed Cost Share Plan Paid Your Responsibility
D2331 (#22) $171 $145 50% $72.50 $72.50
D2331 (#10) $171 $145 50 $72.50 $72.50
D2335 (#11) $268 $0 $0 $268
TOTAL: $413

Therefore, we decided that the Plan does not have to pay for the fillings for teeth # 10, 11, and 22 provided on
November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodontal scalings and root planings of four or more teeth per quadrant, two periodontal scalings and root planings of one to three teeth per quadrant, four gingival irrigations, and two drugs or medicaments dispensed in the office for home use provided on October 22, 2020, and October 23, 2020 by an OON provider.

You asked the Plan to pay for the scalings and planings, gingival irrigations, and drugs or medicaments. You say that you should not be held responsible for these charges. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that no benefits are available for procedures performed by OON providers.

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 covered when they are received OON. The records show that you did not contact the Plan prior to the services being rendered to verify coverage or provider eligibility. Therefore, we decided that the Plan does not have to pay for the two periodontal scalings and root planings of four or more teeth per quadrant, two periodontal scalings and root planings of one to three teeth per quadrant, four gingival irrigations, and two drugs or medicaments dispensed in the office for home use provided on October 22, 2020, and October 23, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.

You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that the items provided were medically necessary.The Plan denied your request. The Plan says the enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed.

The Plan follows Medicare rules. Medicare rules say that the knee orthosis and suspension sleeve are subject to the criteria listed in the Medicare rules section.

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 knee orthosis and suspension sleeve. Our reviewer says that these items were not medically necessary and reasonable. Our physician reviewer found there is insufficient documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

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 knee orthosis and suspension sleeve have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from June 16, 2020, to July 30, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were told that you would owe a $40 copayment per visit and disagree with the additional 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 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs from June 16, 2020, to July 30, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.

The total amount you owe for Medicare Part B drugs is: $1,119.65.

You have been asked to pay the total coinsurance amount of $1,119.65 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription 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 Medicare Part B drugs provided from June 16, 2020, to July 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast ultrasound (76642) provided on September 11, 2020.

You asked the Plan to pay for the breast ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is not appropriate to report unspecified, left, right or bilateral diagnosis codes when the procedure modifier on the claim line does not match the diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 76642 is not supported in the record. Specifically, CPT code 76642 was billed with the RT modifier, but the diagnosis code and records specify the left side. Based on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the breast ultrasound (76642) provided on September 11, 2020.