Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the core build up (D2950) for teeth # 6, 7, 8, 9, and 10.You asked the Plan to pre-approve the dental services. You say that you cannot afford to pay for these services. You also say that you cannot eat and are becoming depressed.The Plan denied your request. The Plan says core build up is not 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, core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve the core build up (D2950) for teeth # 6, 7, 8, 9, and 10.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the emergency room visit provided on September 21, 2019.You asked the Plan to reduce the copayment for the emergency room visit. You say that you originally went to an urgent care center but they were unable to do an ultrasound and you were sent to the emergency room. You say you should only be charged the urgent care copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment per visit for Medicare-covered emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services in the emergency room.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 reduce the copayment for the emergency room visit provided on September 21, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe domiciliary or rest home visit provided on May 29, 2019.You asked the Plan to pay forthe domiciliary or rest home visit. The Plan denied your request. The Plan says this provider is a non-plan provider. The Plan also says that an approved prior authorization request was not on file for this service.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe domiciliary or rest home visit provided on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on August 26, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you feel that you should only owe a $10 copayment because the provider is within the same provider group as your primary care physician.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist office visit. The record shows that you had a visit with a provider that is not your primary care physician on August 26, 2019. Therefore, you are responsible to pay the $40 specialist copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services (92014 and 92133) provided on September 5, 2019 by an out of network (OON) provider.You asked the Plan to pay for ophthalmology services. You say that you attempted to obtain authorization for these services.The Plan denied your request. The Plan says these 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the ophthalmology services (92014 and 92133) provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on September 9, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you should not be responsible for the emergency room copayment because they did not do anything for your blood pressure.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services during your emergency room visit.This means that you have been asked to pay the correctamount 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 forthe emergency room visit provided onSeptember 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 29, 2019.You asked the Plan to waive the copayment for the laboratory work. You say that the lab work services were done in your doctor's office and not an outpatient hospital. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for laboratory services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the laboratory work.You have been asked to pay a $18.29 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the outpatient hospital.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 laboratory work provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhas to reduce the copayment forthe office visit provided on August 26, 2019.You asked the Plan to reduce the copayment forthe office visit. You say that you should be charged a $10 copayment because this copayment has applied to visits to other physicians within the same provider group.The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $10 copayment for each in-network covered Primary Care Provider (PCP) office visit. The Plan says you must pay a $40 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for the office visit.The record shows the provider practices Internal medicine which the Plan considers a Primary Care Physician. Therefore, we decided that the Plan has to reduce the copayment forthe office visit provided on August 26, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the WATS 3D (brush) biopsy testing provided to the enrollee on July 17, 2019.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is an experimental procedure.The Plan must follow Medicare rules. Medicare rules say 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 to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that requested WATS 3D assay meets standard of care guidelines per ASGE recommendations for screening and surveillance of Barrett's, as is the enrollee's indication in this case.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 testing have been met.Therefore, we decided that the Plan has to pay forthe WATS 3D (brush) biopsy testing provided to the enrollee on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B injection or the epidurography on
July 8, 2019.
You asked the Plan to waive the cost share for the Part B injection and the epidurography. You say that the
services were medically necessary and you should not have a charge. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs and a $270 copayment all
other diagnostic and nuclear medicine radiological services.
You have been asked to pay a total of $117.44 for the Part B injection and the epidurography. The Part B
injection falls within the "Medicare Part B prescription drugs" benefit category. The epidurography falls within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service Service Allowed Amount Coinsurance/Copayment Member
Liability
July 8, 2019 Part B injection $12.02 20% $2.40
July 8, 2019 Epidurography $115.04 $270.00 $115.04
Total $117.44
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 Part B injection or the epidurographyon July 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for dual-energy X-ray absorptiometry (77080) provided on August 27, 2019.You asked the Plan to pay fordual-energy X-ray absorptiometry. You say that this claim should be reprocessed.The Plan denied your request. The Plan says this claim must be submitted to the enrollee's primary insurance.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 this claim to the primary insurance. As the secondary insurer, the Plan cannot be held responsible for dual-energy X-ray absorptiometry until the primary insurer has denied the claim for these services.Therefore, we decided that thePlan does not have to pay fordual-energy X-ray absorptiometry (77080) provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for vision care services provided by an in-network provider on October 11, 2019.You asked the Plan to waive the deductible forvision care services. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received vision care services provided by an in-network provider on October 11, 2019. At the time of services rendered you hadnot met your $250 deductible; therefore, you have been asked to pay $53.48 for the services to apply to your deductible. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the deductible forvision care services provided by an in-network provider on October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe skin protecting and positioning wheelchair cushion.You asked the Plan to pre-approvethe wheelchair cushion. You say that the enrollee's current seat cushion has been irreparably damaged/popped and the valve stem has been compromised/rotted off.The Plan denied your request. The Plan says the documentation provided does not support that the criteria has been met.The Plan follows Medicare rules. Medicare rules say that a combination skin protection and positioning seat cushion is covered for a beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. 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 wheelchair cushion. Our reviewer says that this enrollee does not meet the medical necessity criteria. Our physician reviewer found the patient does not have any evidence of postural asymmetry therefore the request for a skin protecting and positioning wheelchair seat cushion is not medically 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 wheelchair cushion have not been met.Therefore, we decided that the Plan does not have to pre-approvethe skin protecting and positioning wheelchair cushion.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hernia surgery billed for services provided to the enrollee on April 16, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.The claim provided shows that CPT code 49507 was billed for services provided on April 16, 2019. However, the medical records provided show that the services at issue were provided on April 15, 2019. The file shows that the Plan made multiple attempts for additional information, however, none was provided. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe hernia surgery billed for services provided to the enrollee on April 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewing x-rays (D0274) and the initial periapical x-ray (D0220) provided on August 29, 2019.You asked the Plan to pay forthe dental services. You say that you were not informed as to the difference between covered and non-covered x-rays.The Plan denied your request. The Plan says the dental services you received are 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 dental services that you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe bitewing x-rays (D0274) and the initial periapical x-ray (D0220) provided on August 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhas to pay forthe x-ray services coded 73130 provided on July 2, 2019.You asked the Plan to pay forthe x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the claim is missing the required anatomic-specific modifier.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 73130 is radiologic examination, hand; minimum of 3 views.We find that CPT code 73130 is supported in the medical record. Specifically, in the additional information provided by the plan, a claim with the correct anatomic-specific modifier was billed. Based on this information, we decided that Medicare rules for coverage of the x-ray services have been met.Therefore, we decided that the Plan has to pay forthe x-ray services coded 73130 provided on July 2, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia services coded 01710 provided on March 5, 2019.You asked the Plan to pay forthe anesthesia services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are a duplicate.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 01710 is Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; not otherwisespecified.We find that CPT code 01710 is not supported in the medical record. Specifically, this claim was denied as a duplicate. Another claim for the same date of service under a different claim number was billed with the same CPT code and modifier code. A previous claim has already been paid. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay forthe anesthesia services coded 01710 provided on March 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided from December 4, 2018 to January 31, 2019.You asked the Plan to pay for home infusion therapy services. You say that you are respectfully requesting reimbursement for these services.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this code is not payable by Medicare.The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy services provided from December 4, 2018 to January 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 6, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This meansthat the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on August 6, 2019.