Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for an office visit (99214) provided on October 28, 2019.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this provider is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that in order to be eligible, nurse practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians' services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have been met. Specifically, the provider in this case is a NP, for which Medicare states payment can be made. The NP has their own NPI on the claim form (in addition to the Billing Provider's NPI). The Plan states that the rendering provider taxonomy submitted on the claim was that of a Registered Nurse (RN). The claim form within the record does not show that a taxonomy of RN was submitted, and the Plan denial rationale is not substantiated. Therefore, we decided that the Plan has to pay for an office visit (99214) provided on October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on December 18,
2019.
You asked the Plan to pay for the nursing facility care. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network
providers available.
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 nursing facility care (99309) provided on
December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on October 3, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service 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.
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 find that CPT code 99291 is not supported in the record. Specifically, the record does not indicate the
amount of time spent rendering the critical care services. Based on this information, we decided that Medicare
rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not
have to pay for critical care services (99291) provided on October 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 13, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that taking out a polyp is standard for a screening colonoscopy. You say that this should be covered in full. 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 $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center. You have been asked to pay $232.14, which is less than the standard $350 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that biopsies were performed and a polyp was removed, which are considered surgical procedures.
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 colonoscopy provided on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 18, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include valid physician order/lab requisition or medical records signed by the ordering physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on August 12,
2019.
You asked the Plan to waive the copayment for a breast biopsy. You say that you paid a $125 copayment in the
past and disagree with the 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 a $0
copayment for any surgical procedures provided during a colorectal screening, a $150 copayment for nonsurgical
visits and a $325 copayment for each visit to a hospital outpatient surgical department.
You received a breast biopsy on August 12, 2019 at an outpatient hospital facility. A breast biopsy is
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment.
You have been asked to pay a $325 copayment for a breast biopsy. A breast biopsy falls within the outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for a breast biopsy provided on August 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on January 2, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you feel that the CT scan should be
considered as an abdominal aorta screening. 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 $125
copayment for each diagnostic service.
You have been asked to pay a $125 copayment for a CT scan. A CT scan falls within the outpatient diagnostic
tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for a CT scan provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99212) provided on November 13, 2019.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the documentation submitted does not support CPT
code 99212.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the office visit have not been met. Specifically, the record does not indicate that CPT code 99212
was rendered on this date of service. Therefore, we decided that the Plan does not have to pay for an office visit
(99212) provided on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0481 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 G0481 is definitive drug testing, 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation of testing of 8-14 drug classes. 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 drug testing rendered on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a raised toilet seat purchased on December 7, 2019.
You asked the Plan to reimburse you for a raised toilet seat. You say that the Plan should reimburse you. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to reimburse you for a raised toilet seat purchased on December 7, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on February 24, 2020. You asked the Plan to waive the copayment for the x-ray. You say that you do not believe you should owe a copayment and you were not informed you would be billed. 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 $20 copayment for each in-network basic imaging service (e.g., general x-rays or ultrasound). You have been asked to pay a $20 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the x-ray provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided out of network on January 9,
2020.
You asked the Plan to pay for this service. You say that the Plan should cover these services. The Plan denied
your request. The Plan says you did not have prior authorization for out of network chiropractic care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that chiropractic services require prior authorization and are not covered out of network. The provider
in this case is not a network provider with the Plan. The Plan has network providers available who can provide
the services at issue in this appeal. The Plan did not pre-approve this service. 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
chiropractic services provided out of network on January 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cervix conization provided on January
31, 2020.
You asked the Plan to waive the copayment for the cervix conization. You say that you weren't informed you
would owe a copayment. You say that you are unable to afford this amount. 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 $325
copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital
facility.
You have been asked to pay a $325 copayment for the cervix conization. The cervix conization falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The cervix conization is considered a surgical procedure. 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 cervix conization provided on January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract removal provided on October 16, 2019 and December 11, 2019.
You asked the Plan to waive the copayments for cataract removal. You say that you disagree with the 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 a $145 copayment for outpatient surgery and other medical services provided at ambulatory surgical centers. You received cataract removal surgeries on October 16, 2019 and December 11, 2019. Therefore, you are responsible to pay a $145 copayment per each service. The total amount you owe is: $290. You have been asked to pay the total copayment amount of $290 for cataract removal. Cataract removal falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for cataract removal provided on October 16, 2019 and December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, topical application of fluoride -
excluding varnish, and prophylaxis provided on December 11, 2019 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, topical application of fluoride, and prophylaxis. You
say that you were unaware that this provider had opted out of your health plan. The Plan denied your request.
The Plan says the treating provider is not a network provider. The Plan also says that no benefits are available
for procedures performed by OON providers or outside of the providers contracted period.
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 periodic
oral evaluation, topical application of fluoride - excluding varnish, and prophylaxis provided on December 11,
2019 by an OON provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthosis provided on January 15, 2020.
You asked the Plan to pay for the wrist hand orthosis (L3916). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. The medical records are from a different physician than the ordering physician. The documentation submitted did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthosis (L3916) have not been met. Therefore, we decided that the Plan does not have to pay for the wrist hand orthosis provided on January 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on November 22, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was falsely titled as surgery. You say that the copayment for surgery is incorrect. The Plan denied your request. The Plan says 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 $400 copayment for in-network, Medicare-covered outpatient hospital surgery services. You have been asked to pay a $400 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The colonoscopy with biopsy is considered a surgical procedure. 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 colonoscopy provided on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight pectoral protector.
You asked the Plan to pre-approve a lightweight pectoral protector. You say that you want a pectoral protector
to prevent sternum fractures in case you fall down. The Plan denied your request. The Plan says pectoral
protectors are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Medicare does
not pay for precautionary equipment. Therefore, we decided that the Plan does not have to pre-approve a
lightweight pectoral protector.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a sleep study provided on December 3, 2019.
You asked the Plan to pay for the sleep study. The Plan denied your request. The Plan says non-emergent, nonurgent
services with out-of-network providers require prior authorization.
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 a sleep study provided on December 3, 2019.