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

We decided that the Plan does not have to waive the copayment for the CT scan provided on June 6, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that this is a preventive service. You say
that you shouldn't have to pay more than usual. 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 $200
copayment for advanced imaging services.
You have been asked to pay $58.10, which is less than the standard $200 copayment for the CT scan. The 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 the CT scan provided on June 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan.
You asked the Plan to pre-approve the Zioptan. You say that the enrollee has been stable on this medication
since 2016. The Plan denied your request. The Plan says the requested medication is not covered under your
medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zioptan.
Benefits for Zioptan may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based fillings (D2335x2 and D2331x2) provided on November 21, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that you have exceeded the number of allowed fillings for the calendar year.
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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the restorations (fillings) have not been met. Specifically, you have exceeded the number of allowed fillings for the calendar year. Therefore, we decided that the Plan does not have to pay for the resin-based fillings (D2335x2 and D2331x2) provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on November 19, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and 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 $5 copayment per primary care provider visit. The record shows that you had an office visit on November 19, 2019 that went beyond an annual wellness visit. Therefore, you are responsible to pay the $5 copayment. You have been asked to pay a $5 copayment for an office visit. An office 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 for an office visit provided on November 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysical therapy. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 forthe medical services provided on June 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to process the claim as in-network for the electrocardiogram (93010) provided on June 13, 2019.You asked the Plan to process the claim as in-network for the electrocardiogram. You say that the nearest in-network facility is 270 miles away so you would like this reprocessed at the in-network rate. The Plan denied your request. The Plan says there is participating facility 1.6 miles away from your home.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 40% coinsurance for Outpatient Diagnostic Tests. You have been asked to pay $3.48 for the EKG. The allowed amount for this service is $8.70. 40% of $8.70 is $3.48. You have been asked to pay 40% coinsurance for the electrocardiogram. The electrocardiogram falls within the Outpatient Diagnostic Tests benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. Please note that the out-of-network cost share amount is to your financial benefit. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to process the claim as in-network for the electrocardiogram (93010) provided on June 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 98943) provided from
October 18, 2019, to November 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not covered
when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the chiropractic services (CPT 98943) provided from October 18, 2019, to
November 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on September 5, 2019.
You asked the Plan to pay for the ambulance services. You say that you don't think you should have to pay the whole bill. The Plan denied your request. The Plan says the modifier GY is present on the claim which carries enrollee responsibility and the provider will not remove the modifier or rebill as a non-emergency transport.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the provider submitted their claim for payment with a GY modifier that indicates that the services provided were non-covered by Medicare. The ambulance provider has submitted a claim that cannot be paid based on Medicare billing guidelines. Because the provider is out-of-network, the plan cannot over-ride the claim. Therefore, we decided that the Plan does not have to pay for services provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on April 24, 2019.
You asked the Plan to pay for outpatient hospital services. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the services were not emergent or urgent in nature.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 outpatient hospital services. Our reviewer says that these services do not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee's condition could have been treated by a provider within the Plan's network. The Plan offered in-network ophthalmology options for the enrollee. There was no emergent condition or special services required that would have necessitated treatment by this out-of-network provider.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided on April 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on October 12, 2019
You asked the Plan to waive the copayment for the MRI. You say that you do not want to pay for the MRI. 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 $250 copayment for covered diagnostic radiology services in the outpatient department of a network hospital or facility. You have been asked to pay a $250 copayment for the MRI. The MRI 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 MRI provided on October 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine tab 10mg.
You asked the Plan to pre-approve the Cyclobenzaprine tab. You say that you do not think that further physical therapy will be beneficial to the enrollee given the degree of spinal stenosis. The Plan denied your request. The Plan says the requested medication is not covered under your medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine tab 10mg.
Benefits for Cyclobenzaprine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay formedical services provided to the enrollee on June 27, 2018.You asked the Plan to pay forthis claim. You say that this claim should be paid. The Plandenied your request. The Plan says this claim was not filed timely. The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for this claim was not filed until December 20, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay formedical services provided to the enrollee on June 27, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the heart rendered to
the enrollee on October 17, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid primary
diagnosis code. 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 computed tomography (CT) scan
of the heart rendered on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on October 7, 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 77002 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 77002 is fluoroscopic guidance for needle placement (eg,
biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure).
We find that CPT code 77002 is not supported in the medical record. Specifically, this code is an add-on code
and it was not billed with a required primary procedure code. 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 services rendered to the enrollee on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided to the enrollee on November 13, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.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 means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the telehealth services provided to the enrollee on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology rendered to the enrollee on August 9, 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 88112 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 88112 and 88173. Code 88112 is a column II code with a modifier indicator of 1 when billed with column I code 88173. Code 88112 was not billed with an appropriate modifier to allow for separate payment. The -59 modifier is not correctly billed, as the documentation does not support a separate and distinct service. Therefore, we decided that the Plan does not have to pay for the cytopathology rendered to the enrollee on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for initiation fees on December 3, 2019.
You asked the Plan to pay for initiation fees. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says this is not a covered benefit. The Plan states this service is not covered under your contract under any normal circumstance.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Initiation fees are not a covered benefit. Your EOC clearly states, the Plan does not reimburse for initiation or registration fees, prorated fees, annual fees, account freeze fees, maintenance fees and any miscellaneous fees or other penalties, equipment purchase or rental, any activities that take place in a private residence or private club (including private golf / country clubs), food / supplements, any type of personal / private training or lessons, player's club or other discount membership and walking or guided tour activities. Therefore, we decided that the Plan does not have to pay for initiation fees on December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (80307 and G0482) provided to the enrollee on August 12, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says codes 80307 and G0482 are not supported. The documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician); therefore,the billed code cannot be verified. Of note, the submitted order and laboratory results are for a different date of service and the custom profile is for a different ordering provider. The Plan states multiple attempts were made to obtain additional information from the provider.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met.Therefore, we decided that the Plan does not have to pay for definitive drug testing (80307 and G0482) provided to the enrollee on August 12, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT services. You say that the records provided support the need for the requested CT scan services. The Plan denied your request. The Plan says that the doctor's notes do not show the reason this test is being done so soon.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 pre-approve the CT services. Our reviewer says that the requested CT is medically necessary and reasonable. Our physician reviewer found the enrollee is noted to have multiple aortic and iliac aneurysms. The enrollee underwent intervention on one of the aneurysms in March 2020. The provider is now wanting to evaluate the intervention via imaging. Not only will such imaging evaluate the aneurysm that was treated, but it will also allow for follow-up on the remaining aneurysms, which appear to have not yet been treated. 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 CT services have not been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) services.
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: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 6, 2019 and billed under code G0480.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Plan says that the claim submitted for payment is incomplete and cannot be paid as 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 claim submitted cannot be paid as billed due to a lack of medical record documentation to support the services billed. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 6, 2019 and billed under code G0480.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided on August 11, 2019.You asked the Plan to waive the copayment forambulance services. 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 $200 copayment for ambulance services. You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forambulance services provided on August 11, 2019.