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

We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943)
provided February 3, 2020 to March 11, 2020.
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 these services are not a covered benefit under
your contractual policy.
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 Plan provides a benefit that exceeds that of
Medicare coverage.
We looked at the case file and the Plan's rules. Based upon this information, we decided that the Plan's rules
for coverage of these services have not been met. Specifically, the Plan covers routine spinal adjustments when
Medicare criteria may not be met. Neither Medicare nor your Plan's supplemental benefit covers adjustments
of areas other than the spine as described by code 98943. Therefore, we decided that the Plan does not have to
pay for the extraspinal chiropractic manipulative treatment (98943) provided February 3, 2020 to March 11,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased February 17, 2020.
You asked the Plan to pay for the hearing aids. You say that the list of benefits state you are entitled to $500
every 3 years for hearing aids. You do not understand why you would have to pay $2000 more to get the same
hearing aid in order to get the $500 benefit. The Plan denied your request. The Plan says there is no coverage if
hearing aids or related services are received from an out of network provider.
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 purchased from an in network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids purchased February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 17, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because the claim was originally processed without a copayment. 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 $30 copayment for specialist visits. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the inpatient hospital services provided from February 3, 2020to February 5, 2020.You asked the Plan to waive the deductible for the inpatient hospital services. The Plan denied your request. The Plan says that there is a deductible for inpatient services.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,364 deductible for Inpatient hospital care. The item or service you asked the Plan to waive the deductible for falls within the benefit category Inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,364 deductible for Inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient hospital services was received on February 3, 2020 to February 5, 2020.Therefore, we decided that the Plan does not have to waive the deductible for the inpatient hospital services provided from February 3, 2020 to February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) provided February 19, 2020 by an
out of network provider.
You asked the Plan to pay for the dental services. You say that you went out of network because the plan
representative never got back to you regarding who you could see in network and you were experiencing a lot
of pain. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network
provider.
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 if the services is received out of network. Therefore, we decided that
the Plan does not have to pay for limited oral exam (D0140) provided February 19, 2020 by an out of network
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 17, 2019.
You asked the Plan to pay for the drug testing. You say that this was medically necessary testing. The Plan denied your request. The Plan says there is no evidence that this provider is actively treating the enrollee for a specific medical condition. The provider did not submit records showing that this testing was ordered by a physician involved in the enrollee's care.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on January 25, 2020.
You asked the Plan to waive the copayment for a breast ultrasound. You say that you disagree with the charges because you already paid the copayment. 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 $100 copayment for X-rays provided in an outpatient hospital facility. You have been asked to pay the allowed amount of $73.23, which is less than the $100 copayment for a breast ultrasound. A breast ultrasound 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 breast ultrasound provided on January 25, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for an inpatient stay for hip replacement surgery for the enrollee.
You asked the Plan to pay for the stay. You say that this is medically necessary. The Plan denied your request. The Plan says that the decision remains to approve as outpatient, but not inpatient.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the stay. Our reviewer says that the documentation supports that the criteria for an inpatient stay is met in this case. Our physician reviewer found the enrollee is indicated for left total hip replacement due to severe rheumatoid arthritis. Comorbidities have been reported to include tuberculosis and anemia. The provider has requested inpatient stay due to her rheumatoid arthritis (that would require a longer recovery for mobilization) and her tuberculosis (that would require monitoring by a pulmonologist.) Additionally, records note a history of anemia. Inpatient admission is supported in this case to allow for pulmonary, rheumatology, and hemodynamic monitoring. Therefore, this request for inpatient stay for the approved left total hip replacement is medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stay have been met. Therefore, we decided that the Plan has to pay for an inpatient stay for hip replacement surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit (99335) provided on November 19, 2019 by an out of network (OON) provider.You asked the Plan to pay foran OON domiciliary or rest home visit. You say that this was a medically necessary service provided in good faith.The Plan denied your request. The Plan says this was not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora domiciliary or rest home visit (99335) provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 25,
2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you should not owe a copayment
for a telehealth visit during a public emergency. 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 $50
copayment for specialist services.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for a specialist visit provided on March 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bed alarm coded as A9280.
You asked the Plan to pre-approve the bed alarm. You say that the enrollee has a history of gastric cancer and
Alzheimer's disease which put the enrollee at a high risk of falling. The bed alarm would greatly decrease the
chance of injury which means it is medically necessary. The Plan denied your request. The Plan says this is not
a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The plan provides as list of noncovered codes which includes A9280
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Although it may be
appropriate, it does not meet the definition of DME as it does not directly treat a medical condition. Therefore,
we decided that the Plan does not have to pre-approve a bed alarm coded as A9280.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation management services
provided from January 24, 2020 to January 29, 2020.
You asked the Plan to waive the coinsurance for the radiation management services. You say that you did not
have chemotherapy or radiation treatments at this facility and did not start treatments until February. The Plan
denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for each Medicare-covered radiation therapy service.
You have been asked to pay a total of $359.48 coinsurance for the radiation management services. The
radiation management services fall within the "Outpatient diagnostic tests and therapeutic services and
supplies" benefit category. The record shows you were billed for radiation preparation codes and the medical
records show the provider creating a radiation treatment plan. See chart below.
Date of Service Service Allowed Amount Coinsurance Member Liability
January 24, 2020 Special radiation
treatment
$123.70 20% $24.74
January 24, 2020 Radiation treatment
devices, design, and
construction
$48.66 20% $9.73
January 24, 2020 Management of
radiation treatment
simulation
$469.01 20% $93.80
Date of Service Service Allowed Amount Coinsurance Member Liability
January 29, 2020 Management
radiation treatment,
3D
$455.98 20% $91.20
January 29, 2020 Radiation treatment
devices, design, and
construction
$357.36 20% $71.47
January 29, 2020 Calculation of
radiation treatment
$185.34 20% $37.07
January 29, 2020 Management
radiation treatment,
complex
$157.37 20% $31.47
Total $359.48
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 coinsurance for the radiation management services provided from January
24, 2020 to January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on January 30, 2020.You asked the Plan to pay for the bone replacement graft. You say that you agreed to be put on a payment plan for the bone graft since you were not sure if the services were covered by the Plan. You also say that you are unable to afford this payment.The Plan denied your request. The Plan says this service is not covered by your plan.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 pay for the bone replacement graft for ridge preservation (D7953) provided on January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on April 17, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that the X-ray was ordered as part of a
physical and you should not be responsible for 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 $50
copayment for X-rays provided in an outpatient hospital facility.
You received an X-ray at an outpatient hospital facility on April 17, 2020. X-rays are not included in physical
exams and are subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for an X-ray. An 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
an X-ray provided on April 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 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 procedure code 81163 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 81163 is BRCA1 (BRCA1, DNA repair associated),
BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full
sequence analysis.
We find that CPT code 81163 is not supported in the medical record. Specifically, the documentation does not
support that full sequence analysis for BRCA testing was performed. The records support that a more
appropriate code is available for the services. 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
laboratory services rendered on October 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from January 14, 2020 to January 18, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. The Plan denied your request. The Plan says that cost-sharing is a contractual obligation.
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 $260 copayment for each day for days 1 to 7 for Medicare-covered hospital care. You have been asked to pay a $1,040 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1 to 7 for Medicare-covered hospital care 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 inpatient hospital services provided from January 14, 2020 to January 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on March 6, 2020 by an out of network (OON) provider.You asked the Plan to pay for radiology services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. 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 for radiology services provided on March 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 9, 2020.
You asked the Plan to waive the copayment for these services. You say that you were not charged a copayment prior to 2020. The Plan denied your request. The Plan says the copayment was 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 $20 copayment per visit to a specialist.
Review of the file shows that you received specialist services on April 9, 2020. Per your contract with the Plan, there is a $20 copayment per visit to a specialist. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $8.98. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $8.98 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on April 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 25, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Comprehensive Genomic Profile (CGP) testing (Guardant-360 and NEXT-Generation) requires use of CPT 81479.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on February 25, 2020.