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

We decided that the Plan does not have to pay forthe digital breast tomosynthesis rendered to the enrollee on September 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 77062 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 77062. This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe digital breast tomosynthesis rendered to the enrollee on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory services provided from October 21, 2019 to October 23, 2019.
You asked the Plan to waive the copayments for laboratory services. You say that all of the laboratory services should have been taken during one visit, not two. 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 laboratory services. You received laboratory services on October 21, 2019 and October 23, 2019. Therefore, you are responsible to pay a $40 copayment per each service. The total amount you owe is: $80.00. You have been asked to pay the total copayment amount of $80.00 for laboratory services. Laboratory services 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 for laboratory services provided  from October 21, 2019 to October 23, 2019.
We note your complaint that laboratory services were rendered on two separate occasions instead of one. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora colonoscopy provided on October 31, 2019.You asked the Plan to waive the copayment fora colonoscopy. You say that you were not informed that you would owe a copayment for a diagnostic colonoscopy.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 $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a diagnostic colonoscopy on October 31, 2019 due to abdominal pain. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for a colonoscopy. A colonoscopy 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment fora colonoscopy provided by on October 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of IRF care.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 medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehabilitation nursing care. While he may benefit from continuing therapy, there is no evidence of the need for an intensive therapy program with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysician services provided on September 6, 2019.You asked the Plan to waive the copayment forphysician services. You say that you never saw the physician 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 $5 copayment for primary care physician visits. The medical recordsshow thatphysician serviceswere rendered on September 6, 2019. Therefore, you are responsible to pay the $5 copayment. You have been asked to pay a $5 copayment for physician services. Physician services fallwithin 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 forphysician services provided on September 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71046) provided on April 1, 2019. You asked the Plan to pay forthe x-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were out-of-network and were not preauthorized or emergent.Medicare rules say thatplans 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 wouldrequire the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71046) provided on April 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 13, 2019 You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent 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 servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon September 13, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on July 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient lab work. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 outpatient lab work provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran x-ray provided on October 31, 2019.You asked the Plan to waive the copayment forthe x-ray. You say that you have always paid a $40 copayment regardless of how many x-rays were taken. You say already paid a $15 copayment and you are still being billed $62.76. 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 Medicare-covered x-rays and ultrasounds. 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 x-ray.You have been asked to pay a $37.76 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 foran x-ray provided on October 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extracapsular cataract removal provided on October 28, 2019.
You asked the Plan to waive the copayment for the extracapsular cataract removal. You say that you cannot afford 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 $225 copayment for surgery services provided in an ambulatory surgical center for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received the extracapsular cataract removal on October 28, 2019. The extracapsular cataract removal is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $225 copayment. You have been asked to pay a $225 copayment for the extracapsular cataract removal. The extracapsular cataract removal 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 the extracapsular cataract removal provided on October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on June 24, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 to enrollee on June 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora transthoracic echocardiography (93306) provided on July 17, 2019.You asked the Plan to waive the copayment forthe echocardiography. You say that your out of pocket maximum has been met.The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Diagnostic Tests. You have been asked to pay a $150 copayment for the echocardiography. The echocardiography falls within the Diagnostic Tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The record shows you had not met your out-of-pocket maximum for in-network services at the time services were rendered. 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 transthoracic echocardiography (93306) provided on July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab work provided on August 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab work. You say that these services were rendered due to the time urgency of the results.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider is also out-of-network.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 foroutpatient lab work provided on August 19, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays provided on October 31, 2019.
You asked the Plan to waive the copayment for the x-rays. You say that you have always paid a $40 copayment regardless of how many x-rays were taken. You say already paid a $15 copayment and you are still being billed $62.76. 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 Medicare-covered x-rays and ultrasounds. You have been asked to pay a $40 copayment for the x-rays. The x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
October 31, 2019
Wrist x-ray
$31.06
$40.00
$31.06
October 31, 2019
Hand x-ray
$8.94
$40.00
$8.94
Total
$40.00
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-rays provided by on October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT Scan of the head or brain (70450) provided on October 17, 2019.You asked the Plan to pay for the CT Scan. You say that the member received multiple services on the same date of service. The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.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, we have confirmed that code the CT Scan has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a CT Scan of the head or brain (70450) provided on October 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection provided on October 10, 2019.You asked the Plan to waive the copayment for a sacroiliac joint injection. You say that you disagree with the outpatient hospital 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 $325 copayment for surgery services provided in an outpatient hospital facility.You received a sacroiliac joint injection on October 10, 2019. A sacroiliac joint injection 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 sacroiliac joint injection. A sacroiliac joint injection falls within the outpatient surgery, including services provided at hospital required. 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 fora sacroiliac joint injection provided on October 10, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 8, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you have been treated at this clinic for 6
years. You say that all of your previous claims have been paid. The Plan denied your request. The Plan says
there was not an authorization on file for the date of service May 8, 2019. The Plan says the provider in this
case is not a network provider. The Plan also says that you were approved for services with the provider from
December 7, 2018 through February 11, 2019 and the next authorization did not begin until June 10, 2019.
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 laboratory services provided on May 8, 2019
by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forcholangiography (73400) provided on January 30, 2019. You asked the Plan to pay forthe cholangiography. You say that the services were medically necessary.The Plan denied your request. The Plan says the out-of-network services were not preauthorized or emergent.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan.The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that thePlan does not have to pay forcholangiography (73400) provided on January 30, 2019.