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

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 22, 2020.

You asked the Plan to waive the copayment for the specialist office visit. You say that you had to have the procedure done again and you do not believe you should be responsible for the second copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $45 copayment for each covered visit or consultation in an outpatient location with a specialist. 

You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you had a catheter insertion during the office visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 22, 2020.

Your complaint about the doctor's coding error is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided to you on July 28, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this testing is not medically necessary.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. 

You were referred for the lab services by a contract provider. The file does not show that the Plan provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services are considered approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided to you on July 28, 2020.

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 the drug test (CPT code G0483) provided to the enrollee on July 22, 2020.

You asked the Plan to pay for the drug test. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Review of the records show that place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test (CPT code G0483) provided to the enrollee on July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 25, 2020.

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 services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician. 

We looked at the file and Medicare rules. The file shows that the billed procedure codes were not billed with the required -26 modifier. 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 September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist/physician other than the requesting dentist/physician (D9310) provided on November 16, 2020.

You asked the Plan to pay for the diagnostic consultation. You say that you have a $1500 annual benefit for dental services, so you expect all services to be covered up to that amount. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit. The Plan has also offered an explanation for your concern regarding the difference in cost between what the provider billed and what the Plan allows for these services. This amount is negotiated between your Plan and the provider and is not your responsibility. Your financial responsibility is for cost-sharing amounts (when applicable) and for services not covered by the Plan, such as the D9310 service in question. The Plan states that the provider will refund you the difference for the covered services because you paid the full billed amount on the date of service.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, which does include certain exams and evaluations, the requested diagnostic consultation provided by a dentist/physician other than the requesting dentist/physician is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist/physician other than the requesting dentist/physician (D9310) provided on November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (CPT code 99497) for the enrollee provided on February 6, 2020.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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 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 services. Our physician reviewer found there was insufficient documentation to support that there was a formal discussion with the enrollee and family regarding advanced care planning and advance directives which is required to meet criteria. These services were not supported in the medical records. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (CPT code 99497) for the enrollee provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of low cost skin substitute graft services coded C5273 provided on January 8, 2020.

You asked the Plan to pay for the application of low cost skin substitute graft services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.

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 C5273 is application of low-cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children.

We find that CPT code C5273 is not supported in the medical record. Specifically, this service was a high-cost skin substitute application procedure. No high-cost skin substitute product codes were billed with this service. Based on this information, we decided that Medicare rules for coverage of the application of low-cost skin substitute graft services have not been met.Therefore, we decided that the Plan does not have to pay for the application of low cost skin substitute graft services coded C5273 provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for two urgent care visits (G0463) on November 24, 2020 and November 25, 2020.

You asked the Plan to waive the copayments for the urgent care visits. You say that the copayment for the visit should be waived because the issue wasn't fixed the first time. The Plan denied your request. The Plan says a copay is applied per visit. There were two visits, and therefore the correct copayment was applied.

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 urgent care facility visits. 

You have been asked to pay a $50 copayment for each urgent care visit ($100 total). 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 two urgent care visits (G0463) on November 24, 2020 and November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for strapping provided from August 21, 2020,
to October 5, 2020.
You asked the Plan to waive the copayments for strapping. You say that you feel that you should only owe a
specialist copayment and disagree with the high 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 $260
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received strapping at an outpatient hospital facility from August 21, 2020, to October 5, 2020, for a total
of 3 services. Strapping is considered and outpatient surgical procedure. Therefore, you are responsible to pay
the total allowed amount of $547.65, which is less than the total copayment amount.
You have been asked to pay the total copayment amount of $547.65 for strapping. Strapping 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 strapping provided from August
21, 2020, to October 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy received on March 6, 2020.

You asked the Plan to pay for the services. You say that you should not have to pay for this. The Plan denied your request. The Plan says the coinsurance was applied appropriately.

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 Part B medications. 

You have been asked to pay 20$ coinsurance for the services. The services fall within the Part B medications 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 pay for chemotherapy received on March 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for hot or cold pack therapy (97010) provided on November 19, 2020.

You asked the Plan to pay for the hot or cold pack therapy. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says payment for this service is included in the payment for the services for which it is incident.

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 CPT code 97010 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is a bundled service and payment for this service is included in the payment for another service. Based on this information, we decided that Medicare rules for coverage of the hot or cold pack therapy have not been met. Therefore, we decided that the Plan does not have to pay for hot or cold pack therapy (97010) provided on November 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services rendered from October 27, 2020 to November 9, 2020.

You asked the Plan to waive the copayment for these services. You say that the admission status was concurrent with discharge from the hospital. 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 $200 copayment per day for days 1-5 for Medicare-covered services received in an acute rehabilitation or long-term acute care hospital.

Review of the file shows that the enrollee received inpatient rehabilitation services from October 27, 2020 to November 9, 2020. The enrollee has been asked to pay a $200 copayment per day for days 1-5 for these services, for a total of $1,000. These services fall within the Medicare-covered services received in an acute rehabilitation or long-term acute care hospital benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services rendered from October 27, 2020 to November 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for breast biopsy surgery (19081) provided on November 2, 2020.

You asked the Plan to waive the copayment for breast biopsy surgery. You say that you shouldn't have a copayment because of the pain and suffering you went through. The Plan denied your request. The Plan says this processed 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 $250 copayment for outpatient hospital surgery. 

You have been asked to pay a $250 copayment for breast biopsy surgery. 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 breast biopsy surgery (19081) provided on November 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided November 19, 2020.

You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item provided was medically necessary. The Plan denied your request. The Plan says the enrollee previously received an orthosis.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee had the same orthosis at the time a lumbar-sacral orthosis was received. The orthosis they already had serves the same purpose as a lumbar-sacral orthosis. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided November 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the fluorodeoxyglucose provided on October 23, 2020.

You asked the Plan to waive the coinsurance for the fluorodeoxyglucose. You say that you were told the injection would be included in the PET scan. The Plan denied your request. The Plan says the coinsurance 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 10% coinsurance for each Medicare-covered medical supply. 

You have been asked to pay $25, which is 10% of the allowed amount for the fluorodeoxyglucose. The allowed amount is $250 (10% x $250 = $25). The fluorodeoxyglucose falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The fluorodeoxyglucose is considered a medical supply, which applies separate coinsurance. 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 fluorodeoxyglucose provided on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 4, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physician's services. 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 physician's services provided on November 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound supplies rendered on October 1, 2020.

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 enrollee was on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the wound supplies rendered on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on January 4, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 had network providers available who could have provided the services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network provider on January 4, 2021.