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

We decided that the Plan does not have to waive the copayment for the ultrasound and MRI provided on June 4, 2020.
You asked the Plan to waive the copayment for the ultrasound and MRI. You say that you were told you would only have a $40 copayment. You say that you want this bill resolved. 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 $40 copayment for basic radiological services and a $180 copayment for advanced imaging services at an in-network specialist's office. You have been asked to pay a $40 copayment for the ultrasound and a $180 copayment for the MRI. The ultrasound and MRI fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that two different diagnostic tests were performed, which apply separate copayments. 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 ultrasound and MRI provided on June 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided May 29, 2020, to 
June 5, 2020. 
 
You asked the Plan to pay for this service. You say that these claims should be paid. The Plan denied your 
request. The Plan says you did not have prior authorization for out of network 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 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 out of network physician 
services provided May 29, 2020, to June 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are unable to admit to a skilled nursing facility due to COVID restrictions, as they require a 14-day quarantine. You say that you fell and broke bones in different areas. You say that you cannot fully care for yourself and feel that a stay is necessary in order to begin to live independently again. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the care needed in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe arthroscopy services coded 29876 and 29882 provided on June 1, 2020.You asked the Plan to pay forthe arthroscopy 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 not payable.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 29876 and 29882. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the arthroscopy services have not been met.Therefore, we decided that the Plan does not have to pay forthe arthroscopy services coded 29876 and 29882 provided on June 1, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcrown -porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided on July 23, 2020.You asked the Plan to pay forcrown and core build up. You say that the services should be covered.The Plan denied your request. The Plan says the services rendered 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. Specifically, the restorative services you received are not covered under this Plan.Therefore, we decided that the Plan does not have to pay forcrown -porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided on July 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an anticancer regimen comprising Fluorouracil (J9190), Leucovorin (J0640), Oxaliplatin (J9263), Bevacizumab-awwb (Q5107), Dexamethasone (J1100), Palonosetron (J2469), and Aprepitant (J0185) for treatment of biliary tract cancer.

You asked the Plan to pre-approve an anticancer regimen comprising Fluorouracil, Leucovorin, Oxaliplatin, Bevacizumab-awwb, Dexamethasone, Palonosetron, and Aprepitant. You say that this regimen is medically necessary. The Plan denied your request. The Plan says rules for pre-approval have not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 an anticancer regimen comprising Fluorouracil, Leucovorin, Oxaliplatin, Bevacizumab-awwb, Dexamethasone, Palonosetron, and Aprepitant. Our reviewer says that the requested drugs are not medically indicated for the provided diagnosis. Our physician reviewer found that the requested drugs are not FDA-approved for your diagnosis. The use of these drugs in this combination is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an anticancer regimen comprising Fluorouracil, Leucovorin, Oxaliplatin, Bevacizumab-awwb, Dexamethasone, Palonosetron, and Aprepitant have not been met. Therefore, we decided that the Plan does not have to pre-approve an anticancer regimen comprising Fluorouracil (J9190), Leucovorin (J0640), Oxaliplatin (J9263), Bevacizumab-awwb (Q5107), Dexamethasone (J1100), Palonosetron (J2469), and Aprepitant (J0185) for treatment of biliary tract cancer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on September 3, 2020.You asked the Plan to reimburse you forthe dental service. You say that as far as you know you were only given gauze to stop the bleeding. You also say that you paid $175.The Plan denied your request. The Plan says biologic materials to aid in soft and osseous tissue regeneration 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 reimburse you forthe biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on September 4, 2020.You asked the Plan to waive the copayment forthe office visit. You say that your general practitioner sent you to the gynecologist, but they informed you they don't check those medical issues. You say that the copayment should be reimbursed.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 $40 for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that 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 copayment forthe office visit provided on September 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost forthe echocardiography provided on July 15, 2020 and the stress test, myocardial perfusion imaging, regadenoson injection and medical supply provided on July 21, 2020.You asked the Plan to waive the cost forthe echocardiography, stress test, myocardial perfusion imaging, regadenoson injection and medical supply. You say that you always use an in-network doctor to avoid these charges. You say that you cannot pay this bill.The Plandenied your request. The Plan says the cost share 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 20% coinsurance for each Medicare-covered medical supply, a $20 copayment for Medicare-covered non-radiological diagnostic services,a $110 copayment for each Medicare-covered radiological diagnostic serviceand 20% coinsurance for each Medicare-covered Part B drug from an in-network provider. 
You have been asked to pay a total of $495.80 for the echocardiography, stress test, myocardial perfusion imaging, regadenoson injection and medical supply. 
The echocardiography, stress test, myocardial perfusion imaging and medical supply fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The regadenoson injection falls within theMedicare Part B Prescription Drugs" benefit category. The records show that you were charged the in-network rate. 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 forthe echocardiography provided on July 15, 2020 and the stress test, myocardial perfusion imaging, regadenoson injection and medical supply provided on July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital services you received from August 28, 2019, to August 31, 2019.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you do not agree with this aountThe Plan denied your request. The Plan says you were charged this copayment correctly.The rules say aplan 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 $395 copayment per day for days 1-4 for inpatient hospital care. You have been asked to pay a $395 copayment per day for days 1-4 for the inpatient hospital services. You were in the hospital for a total of three days.  Your Evidence of Coverage states that you pay a $395 copayment per day for days 1-4, sothe total copayment due is $1,185 ($395 x 3 days = $1,185.) 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 forinpatient hospital services you received from August 28, 2019, to August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe resin based composite (D2394), the sedative filling (D2940), and the core build up (D2950 x 2) provided from March 9, 2020, to July 17, 2020.You asked the Plan to pay forthe dental services. You say that you broke your tooth. You say that there was not enough tooth to place the crown. You also say that the service should be covered.The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that the provider in this case is not a network provider. The Plan also says there is a 50% coinsurance for the allowed amount for fillings that you receive out of network.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the core build up are not among those covered under this benefit. Additionally, there is a 50% coinsurance of the allowed amount for fillings. This is a contractual obligation  you agreed to when you enrolled in the Plan's dental coverage.Therefore, we decided that the Plan does not have to pay forthe resin based composite (D2394), the sedative filling (D2940), and the core build up (D2950 x 2) provided from March 9, 2020, to July 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5050) provided.

You asked the Plan to pay for hearing aids. You say that the item was medically necessary.The Plan denied your request. The Plan says services must be received in-network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when services are received in network.

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, you received this service from an out-of-network provider.Therefore, we decided that the Plan does not have to pay for hearing aids (V5050) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (S9123) provided on September 25, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says a RAP is required.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S9123 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 pay forthe services (S9123) provided on September 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foran ultrasound and a hysteroscopy provided on June 30, 2020, and September 9, 2020.You asked the Plan to waive the copayments foran ultrasound and a hysteroscopy. You say that the results showed that everything was normal,so you feel that the test was unnecessary.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 $200 copayment for each outpatient surgery and a $10 copayment for each basic imaging service.You received an ultrasound on June 30, 2020. Therefore, you are responsible to pay the $10 copayment. You received a hysteroscopy on September 9, 2020. A hysteroscopy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.  The total amount you owe is: $210. You have been asked to pay the total copayment amount of $210 for an ultrasound and a hysteroscopy. An ultrasound and a hysteroscopy fall within the outpatient hospital 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 copayments foran ultrasound and a hysteroscopy provided on June 30, 2020, and September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for lens sphere single vision plano 4.00 (V2100) and vision service (V2799) provided.

You asked the Plan to pay for vision services and single vision sphere lenses. You say that the services should be covered.The Plan denied your request. The Plan says you received services from an out-of-network provider.

Medicare generally does not cover routine vision and eye wear services. However, the Plan offers a routine vision and eye wear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when rendered at an in-network provider.

We looked at the file and the Plan's rules. You received vision services at an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of vision services and single vision sphere lenses have not been met.Therefore, we decided that the Plan does not have to pay for lens sphere single vision plano 4.00 (V2100) and vision service (V2799) provided.
Your complaint about potentially being told by the Plan that the service would be covered 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 com
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic digital breast tomosynthesis coded 77061 provided on July 8, 2020.You asked the Plan to pay forthe diagnostic digital breast tomosynthesis. You say that you would like the plan to reconsider their denial.The Plandenied your request. The Plan says the services rendered are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Inthis case, the CPT Code Manual definition of code 77061 is diagnostic digital breast tomosynthesis; unilateral.We find that CPT code 77061 is not supported in the medical record. Specifically, this procedure code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of and payment of these services. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay forthe diagnostic digital breast tomosynthesis coded 77061 provided on July 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services you received.

You asked the Plan to waive the deductible for the lab services. You say that you want to know why the Plan didn't cover these services.The Plan denied your request. The Plan says you had not yet met your deductible at the time of the services.  The Plan says that to date, you have only met $149.28 towards your deductible.

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 $500 annual deductible. 

You have been asked to pay for these lab services because you have not yet satisfied your deductible for 2020. 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 deductible for lab services you received.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forimaging services provided to the enrollee on April 9, 2020 and billed under code 76498, "unlisted magnetic resonance procedure."You asked the Plan to pay forthis claim. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says imaging services provided without a valid diagnosis that meets Medicare criteria are not covered. The Plan says that the provider is appealing the denied screening testcoded as 76498 or unlisted magnetic resonance procedure. The diagnosis is elevated PSA. These services are not authorized because this service is not paid as a screening for the diagnosis code listed. Medicare coverage criteria are not 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 code submitted is not covered for the service and/or diagnosis provided. Medicare rules for coverage of this claim have not been met.Therefore, we decided that the Plan does not have to pay forimaging services provided to the enrollee on April 9, 2020 and billed under code 76498, "unlisted magnetic resonance procedure."