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

We decided that the Plan does not have to waive the copayment for an office visit and does not have to waive the coinsurance for a Medicare Part B drug provided on July 9, 2019.
You asked the Plan to waive the copayment for an office visit and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the specialist charges and feel that you should only owe a primary care visit 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 $5 copayment for primary care provider visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You had an office visit on July 9, 2019. Therefore, you are responsible to pay the $5 copayment. You received a Medicare Part B drug on July 9, 2019. The allowed amount is $1.09 and 20% of that is $0.22. The total amount you owe is: $5.22. You have been asked to pay the total amount of $5.22 an office visit and a Medicare Part B drug. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug falls 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 office visit and does not have to waive the coinsurance for a Medicare Part B drug provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 15, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 physician's services provided on January 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for PT provided from October 18, 2019 to
October 31, 2019.
You asked the Plan to waive the copayments for PT. You say that you were told that the Plan would take care
of 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 $40
copayment for outpatient rehabilitation services.
You received PT from October 18, 2019 to October 31, 2019 for a total of 4 visits. Therefore, you are
responsible to pay the total allowed mount of $150.99, which is less than the total copayment amount.
You have been asked to pay $150.99 for PT. PT falls within the outpatient rehabilitation services benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayments for PT provided from October 18, 2019 to
October 31, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care services (T1019) provided from October 14,
2019 to October 16, 2019.
You asked the Plan to pay for personal care services. You say that these services should be paid. The Plan
denied your request. The Plan says these services are not covered under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. The rules also say
that status code "I = Not valid for Medicare purposes.
We looked at the file and Medicare rules. The personal care services at issue are custodial in nature. They were
also billed with code T1019, which has a status code of I and is not valid for Medicare purposes. Based on this
information, we decided that Medicare rules for coverage of personal care services have not been met.
Therefore, we decided that the Plan does not have to pay for personal care services (T1019) provided from
October 14, 2019 to October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for inhalation of nitrous oxide (D9230) provided March 3, 2020.
You asked the Plan to pay for the dental. You say that the summary of benefits does not list any exclusions to
the $1000 benefit. Extractions are listed as a covered benefit without any disclaimers or notes as to what is not
covered as part of the procedure The Plan denied your request. The Plan says this service is not covered under
the plan 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.
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 inhalation
of nitrous oxide (D9230) provided March 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for frames bifocal lenses and progressive lenses purchased
March 2, 2020.
You asked the Plan to pay for the vision services. You say that you have always went to this provider and was
not aware that they are not in-network. The Plan denied your request. The Plan says services obtained from
vendors outside of the network are not covered.
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 purchased from an in-network provider.
We looked at the file and the Plan's rules. Services obtained from vendors outside of the network are not
covered. 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 frames bifocal lenses and progressive
lenses purchased March 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for resin-based composite - two surfaces, anterior tooth 11 (D2331) resin-three surfaces, anterior tooth 7 (D2332) resin-based composite - two surfaces, posterior tooth 12 (D2392) provided February 21, 2020.
You asked the Plan to pay for the dental services. You say that you spoke to a plan representative who said that everything will be covered. You are appealing the denial because of the lack of correct information received. The Plan denied your request. The Plan says the benefit maximum has been exceeded
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 services received are covered benefits however, the $500 benefit maximum has been met. The health plan contract specifically says that after the annual maximum is exhausted, any remaining charges are your responsibility. 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 resin-based composite - two surfaces, anterior tooth 11 (D2331) resin-three surfaces, anterior tooth 7 (D2332) resin-based composite - two surfaces, posterior tooth 12 (D2392) provided February 21, 2020.
Your complaint about the customer service received 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on April 1, 2020.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that the procedure was done in the doctor's office, not a hospital. You say that there is nothing on your card or in the letter of approval indicating that a copayment is required. 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 for MRIs, PET scans, and nuclear cardiac imaging tests, you must pay a $250 copayment for each category of test for each service date. You have been asked to pay a $250 copayment for the myocardial perfusion imaging. The myocardial perfusion imaging 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 myocardial perfusion imaging provided on April 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on February 20, 2020.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you don't have a copayment for routine screenings. 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 $300 copayment for each Medicare-covered outpatient hospital visit. You have been asked to pay a $300 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes. 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 diagnostic colonoscopy provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4 x-rays for decay (D0274) and upper and lower jaw x-ray (D0330) provided December 3, 2019.
You asked the Plan to pay for the dental x-rays. You say that the only reason you went to this provider was because you were told by a plan representative that this provider was a part of the network. The Plan denied your request. The Plan says these services are not covered under the plan 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. 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 4 x-rays for decay (D0274) and upper and lower jaw x-ray (D0330) provided December 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 2, 2020.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to verify the billed code.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 12, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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 tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 11, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 87631 provided on February 23, 2020.
You asked the Plan to pay for CPT code 87631. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. CPT code 87631 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes. Based on this information, we decided that Medicare rules for coverage of CPT code 87631 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 87631 provided on February 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (71045, Q0092, R0070) provided on November 7, 2019.

You asked the Plan to pay for imaging services. You say that these services were medically necessary. The Plan denied your request. The Plan says coverage of these services is the responsibility of Original Medicare.

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 imaging services (71045, Q0092, R0070) provided on November 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services provided to the enrollee on December 19, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.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 forlaboratory services provided to the enrollee on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services from provided to the enrollee August 11, 2019 through August 23, 2019 by a foreign hospital.You asked the Plan to pay forthe services. You say that you are unable to pay these expensesThe Plan denied your request. The Plan says multiple attempts have been made to receive proof of payment without success.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of the services have not been met. Review of the file show that the enrollee received services from a foreign hospital from August 11, 2019 through August 23, 2019. The enrollee's EOC states, if themember has an emergency outside of the U.S. and its territories, they are responsible to pay forthe services renderedupfront and submit to the Planfor reimbursement. Multiple attempts have been made to receive proof of payment without success. Therefore, we decided that the Plan does not have to pay forthe services from provided to the enrollee August 11, 2019 through August 23, 2019 by a foreign hospital.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on December 17, 2019.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation did not include any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP and humidifier provided on October 28, 2019.
You asked the Plan to waive the coinsurance for the CPAP and humidifier. You say that you don't understand why you are being billed for multiple items and why the coinsurance is so high. The Plan denied your request. The Plan says you were charged the coinsurance 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 15% coinsurance for Durable Medical Equipment and related supplies. You have been asked to pay 15% coinsurance for the CPAP and humidifier. The CPAP and humidifier fall within the Durable Medical Equipment and related 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 coinsurance for the CPAP and humidifier provided on October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical trays (A4550) and moderation sedation services (99156 and 99157) provided on December 3, 2019.You asked the Plan to pay forthe surgical trays and moderate sedation services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says these services are included in the payment of other procedures that have been approved.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, per the Physician Fee Schedule, CPT code A4550 has a status code of B which means that payment is always bundled into another service. Additionally, we have confirmed that codes 99156 and 99157 have a bundled relationship with code 64635 and cannot be paid as billed. This code cannot be paid asa separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forsurgical trays (A4550) and moderation sedation services (99156 and 99157) provided on December 3, 2019.