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

We decided that the Plan does not have to waive the copayments for a specialist provider visit and trigger point injections provided on January 18, 2021.

You asked the Plan to waive the copayments for a specialist provider visit and trigger point injections. You say that you are on a strict budget and would have never had the injections at issue if you had known about the copayment. The provider informed you there would be a $50 copayment. The Plan denied your request. The Plan says the correct copayments were applied.

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 $550 copayment for each outpatient hospital and observation service.

You have been asked to pay a $419.25 copayment for trigger point injections and a $50 copayment for a specialist provider visit. a specialist provider visit and trigger point injections fall within the "Outpatient hospital services" benefit category. This means that you have been asked to pay less than or equal to the full and 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 copayments for a specialist provider visit and trigger point injections provided on January 18, 2021.

Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibility from your provider 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation
(A0429, A0425) provided on March 2, 2021.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you should
not have to pay charges. 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 $300
copayment for ambulance services.

You have been asked to pay a $300 copayment for emergency ambulance transportation. The service at issue
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
emergency ambulance transportation (A0429, A0425) provided on March 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided by an occupational therapy assistant on August 26, 2020.

You asked the Plan to pay for occupational therapy. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if the service is not available from a preferred provider. You say that many services were not available on an outpatient basis due to the pandemic and the claim should be processed for payment at the in-network benefit. The Plan denied your request. The Plan says the billed code is not appropriate for the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy provided by an occupational therapy assistant on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit rendered on March 29, 2021.
You asked the Plan to waive the deductible for these services. You say that you were not informed there would be a cost share. The Plan denied your request. The Plan says the deductible was applied correctly.
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 there is $203 yearly deductible for your covered Medicare Part A and B services. The item or service you asked the Plan to waive the deductible for falls within the Medicare-covered primary care doctor visit benefit cateogry. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $203 yearly deductible for your covered Medicare Part A and B services. This cost sharing is a contractual obligation that had not been met at the time these services were received on March 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit rendered on March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99291) provided on November 23 to November 24, 2020.

You asked the Plan to pay for critical care. You say that you have submitted medical records in support of the claim at issue. The Plan denied your request. The Plan says rules for payment have not been met.

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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes."

We asked our coder 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 critical care. Our reviewer says that the claim at issue does not meet criteria for billing or reimbursement consideration. Our coder reviewer found that the medical records submitted do not include sufficient documentation to validate that an "evaluation and management of the critically ill or critically injured patient, first 30-74 minutes" was performed on November 23 through November 24, 2020; therefore, this service cannot be verified.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99291) provided on November 23 to November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 20, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not indicate that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81162, 81201, 81292, 81295, 81298, 81317, 81321, 81401, 81403, 81404, 81405, 81406, 81408, & 88237) provided June 26, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 81162, 81201, 81292, 81295, 81298, 81317, 81321, 81401, 81403, 81404, 81405, 81406, 81408, & 88237 are not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81162, 81201, 81292, 81295, 81298, 81317, 81321, 81401, 81403, 81404, 81405, 81406, 81408, & 88237) provided June 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital care (99233, 99232), provided on July 17, 2014,
through July 25, 2014.

You asked the Plan to pay for the hospital care. You say that you did file the claim timely. The Plan denied
your request. The Plan says the claim was filed past the allowed twelve-month timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.

The record shows that a claim for the hospital care was not filed until March 22, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital care (99233, 99232), provided on July 17, 2014, through July 25, 2014.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (CPT code 64484 and 64483), for the enrollee.

You asked the Plan to pre-approve the injections. You say that the services are medically necessary. The Plan denied your request. The Plan says the procedure is not supported without a treatment plan showing that the enrollee will not exceed the following limits. The Plan states no more than two (2) injections to the area where a nerve root exits (transforaminal) can be done during a single setting. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. The rules say that it is considered not medically reasonable and necessary to perform more than 2 epidural injections in a single setting (e.g., single level bilaterally or two levels unilaterally). Therefore, we decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (CPT code 64484 and 64483), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 5, 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 services were 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 office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on January 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided January 26, 2021.

You asked the Plan to waive the copayment for the emergency ambulance transport. You say that you did not want the ambulance transport and do not agree with the copayment 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 $225 copayment for ambulance services in the United States. 

You have been asked to pay a $225 copayment for the emergency ambulance transport. The emergency ambulance transport 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 service, basic life support, emergency transport (A0429) provided January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided from August 6, 2019, to May 26, 2020.
You asked the Plan to pay for outpatient services. You say that you were told that this Plan was your only insurance, and you had no control over the other policy. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan is your secondary payer and cannot process these claims until they are processed by your primary insurance carrier.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed the
provider to submit these claims to your primary insurance carrier, which the provider indicated they would do
right away. As the secondary insurer, the Plan cannot be held responsible for outpatient services until the
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to
pay for outpatient services provided from August 6, 2019, to May 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation
(A0428, A0425) provided on October 9, 2020.

You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you
want the Plan to pay. 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 $250
copayment for ambulance services.

You have been asked to pay a $247.22 copayment for non-emergency ambulance transportation. The services
at issue fall within the ambulance services benefit category. Since the Allowed Amount for this service is less
than the required copayment of $250, you have been asked to pay only $247.22. 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 non-emergency ambulance transportation (A0428, A0425) provided on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Hyaluronan injection provided on January 22, 2021.

You asked the Plan to waive the cost share for the injection services. You say that you need the injections to avoid having a knee replacement. The Plan denied your request. The Plan says the coinsurance was applied per your 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for the injection services. The services falls 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 cost share for the Hyaluronan injection provided on January 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the cystourethroscopy provided on January 6,
2021.

You asked the Plan to waive the copay for the cystourethroscopy. You say that you were not forewarned of
such a high copay for any procedure. The Plan denied your request. The Plan says that the claim processed
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 $350
copay for each surgical or observation room service you get at an outpatient hospital.

You have been asked to pay a $350 copay for the cystourethroscopy. The cystourethroscopy falls within the
each surgical or observation room service you get at an outpatient hospital 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 copay for the cystourethroscopy provided on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180), and an adjunctive pre-diagnostic test (D0431) provided on April 9, 2021.

You asked the Plan to pay for a comprehensive periodontal evaluation, and an adjunctive pre-diagnostic test. You say that you were not aware that the services would not be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 comprehensive periodontal evaluation (D0180), and an adjunctive pre-diagnostic test (D0431) provided on April 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation
(A0429) provided on June 13, 2018.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you did not
choose this ambulance company and you were told the bill had been resolved. The Plan denied your request.
The Plan says the copayment has been 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 $200
copayment for ambulance services.

You have been asked to pay a $200 copayment for emergency ambulance transportation. The service at issue
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 emergency ambulance transportation (A0429) provided on
June 13, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites provided on March 3, 2021 by an OON provider.

You asked the Plan to pay for the resin-based composites. You say that you have seen this dentist for over five years because they are close to your home and you do not drive. You also say that switching dentists would have been troublesome, which is why you continued to see this dentist. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that you do not have OON benefits.

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. Therefore, we decided that the Plan does not have to pay for the resin-based composites provided on March 3, 2021 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on September 10,
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 97530 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the
services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy services rendered on September 10, 2020.