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

We decided that the Plan does not have to waive the copayment for laboratory services provided on November 27, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that the labs were not done at the hospital and you should not have been billed. 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 $40 copayment for lab services at an in-network outpatient hospital. You have been asked to pay a $40 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the laboratory services were billed by the hospital. 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 laboratory services provided on November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, two endodontic therapies, full mouth debridement, two core buildups, including any pins when required, two apicoectomies, problem focused limited oral evaluation, and first intraoral periapical x-ray provided from August 8, 2019, to July 31, 2020.
You asked the Plan to pay for the dental services. You say that you would like these services to be covered. The Plan denied your request. The Plan says the complete series of intraoral x-rays, endodontic therapy, full mouth debridement, core buildup, including any pins when required, apicoectomy, problem focused limited oral evaluation, and first intraoral periapical x-ray are not covered benefits.
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. The rules also 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the complete series of intraoral x-rays, endodontic therapy, full mouth debridement, core buildup, including any pins when required, apicoectomy, problem focused limited oral evaluation, and first intraoral periapical x-ray are not among those covered under this benefit. The record also shows that a claim for the comprehensive oral evaluation provided on August 8, 2019 was not filed until December 4, 2020. 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 for the comprehensive oral evaluation, complete series of intraoral x-rays, two endodontic therapies, full mouth debridement, two core buildups, including any pins when required, two apicoectomies, problem focused limited oral evaluation, and first intraoral periapical x-ray provided from August 8, 2019, to July 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 18, 2020.

You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on September 18, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI and does not have to waive the
coinsurance for Medicare Part B drugs provided on September 29, 2020.
You asked the Plan to waive the copayment for an MRI and to waive the coinsurance for Medicare Part B
drugs. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay
diagnostic radiology services. Your contract with the Plan also clearly says that you must pay 20% coinsurance
for Medicare Part B drugs.
You received an MRI on September 29, 2020. Therefore, you are responsible to pay the $150 copayment.
You received Medicare Part B drugs on September 29, 2020. The total allowed amount is $27.75 and 20% of
that is $5.55.
The total amount you owe is: $155.55.
You have been asked to pay the total amount of $155.55 for an MRI and Medicare Part B drugs. An MRI falls
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B
drugs fall within the Medicare Part B prescription drugs 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 MRI and does not have to
waive the coinsurance for Medicare Part B drugs provided on September 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the PET scan provided on November 20,
2020.
You asked the Plan to waive the copayment for the PET scan. You say that you were advised to go to the
urgent care facility because the copayment would be less. You say that the bill was wrongfully coded, and you
want the bill adjusted to reflect the correct amount due. 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 $275
copayment for advanced imaging services provided at an in-network outpatient hospital.
You have been asked to pay a $275 copayment for the PET scan. The PET scan falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The records show the PET scan was
billed by the hospital. 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 PET scan provided on
November 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on December 8, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that your primary care doctor asked you to get a blood draw one week before your appointment. 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 $40 copayment for each Medicare-covered laboratory test in an outpatient hospital facility. You have been asked to pay a $40 copayment for laboratory services. The laboratory services fall 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 laboratory services provided on December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services received on October 15, 2020.
You asked the Plan to waive the copayment for the services. You say that this should be reconsidered. The Plan denied your request. The Plan says the claim 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 $35 copayment for laboratory services. You have been asked to pay a $35 copayment for the services. The services fall within the laboratory 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 for laboratory services received on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for BRCA 1 and BRCA 2 testing (81162) provided on October
5, 2020.
You asked the Plan to pay for BRCA 1 and BRCA 2 testing. You say that this was medically necessary. The
Plan denied your request. The Plan says this was not indicated.
The Plan must follow Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 testing is covered by
Medicare for individuals with a breast cancer diagnosis only when the criteria listed in the LCD have been met.
We looked at the file and Medicare rules. The record shows that the enrollee is female, was diagnosed with
breast cancer at age 83, and does not have a family history of relevant cancers that would indicate this testing.
Based on this information, we decided that Medicare rules for coverage of BRCA 1 and BRCA 2 testing have
not been met. Therefore, we decided that the Plan does not have to pay for BRCA 1 and BRCA 2 testing
(81162) provided on October 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 11, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care, per day (99232) provided from September 4, 2019, through September 13, 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 these services are not payable as the claim was submitted untimely.
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 subsequent hospital care was not filed until September 17, 2020. 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 for the subsequent hospital care, per day (99232) provided from September 4, 2019, through September 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered.

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 billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on September 9, 2020.
You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 duplex scan. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a duplex scan provided on September 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid (V5257) received from an out-of-network
provider.

You asked the Plan to pay for the hearing aid. You say that the hearing aids should be covered. The Plan denied
your request. The Plan says you may receive hearing aids from any network provider. You obtained this
hearing aid 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 they are obtained from a 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 aid have not been met. Therefore, we decided that the Plan does not have to pay for the
hearing aid (V5257) received from an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam, bitewing x-rays, cleaning, and filling.

You asked the Plan to reimburse you for the dental services. You say that you were unaware that your plan included dental benefits. You say that your dentist did not tell you that your plan had changed. You also say that you have an appointed representative payee through the Social Security Administration that pays your bills. You say that had you been made aware of the change where dental services were covered, you would have been able to access this benefit in a timely manner. The Plan denied your request. The Plan says claims need to be submitted withing 365 days from the date of service. The Plan also says that the claims for these dates of service were not received within this time frame.

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 the dental services was not filed until December 8, 2020. 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 reimburse you for the oral exam, bitewing x-rays, cleaning, and filling.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is intended for monitoring rather than therapeutic reasons.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the case file does not indicate if the enrollee is on insulin or that insulin treatment decisions are being adjusted based on the results of the testing. The requested service cannot be recommended. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.

You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because this appointment was required for your surgery and it was a drive-through test site. 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 $15 copayment per visit for an in-network specialist.

You have been asked to pay a $15 copayment for the specialist office visit. The specialist 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 the specialist office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) polycarbonate lens (V2784) progressive lens (V2781) tint, photochromatic, per lens (V2744) provided November 11, 2020.
You asked the Plan to pay for the vision services. You say that you do not believe you should owe the amount due. The Plan denied your request. The Plan says eyewear is only covered after each cataract surgery.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the plan covers 1 pair of eyeglasses or contact lenses after each cataract surgery.
We looked at the file and the Plan's rules. The plan covers 1 pair of eyeglasses or contact lenses after each cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) polycarbonate lens (V2784) progressive lens (V2781) tint, photochromatic, per lens (V2744) provided November 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport from a skilled nursing facility (SNF) to the x-ray facility on September 18, 2020.
You asked the Plan to pay for the ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says this claim is the responsibility of the skilled nursing facility under consolidated billing.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Medicare rules say that ambulance services must be billed based on the enrollee's patient status at the time of transport. At the time of transport, you were considered an "inpatient' under Part A. These transport services are not separately payable under Medicare Part B and must be submitted to the institution initiating the transport. Therefore, we decided that the Plan does not have to pay for the ambulance transport from a SNF to the x-ray facility on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care.

You asked the Plan to waive the copayment for vision care. 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 $20
copayment for vision care provided in a specialist's office.

You have been asked to pay a $20 copayment for vision care. Vision care falls within the vision 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 vision care.