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

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on January 4,
2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a colonoscopy screening,
and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for outpatient surgery, including services provided at ambulatory surgical centers.
The medical records show that you had polyps removed during a colonoscopy provided on January 4, 2021.
Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $150
copayment.
You have been asked to pay a $150 copayment for a colonoscopy. A colonoscopy falls within the outpatient
surgery, including 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 copayment for a colonoscopy provided on January 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the knee arthroplasty provided on December 21, 2020.
You asked the Plan to reduce the coinsurance for the knee arthroplasty. You say that the surgery was scheduled for 2021 so the enrollee would have had less coinsurance due. The Plan denied your request. The Plan says the enrollee was charged this 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Outpatient Surgery Services. The enrollee has been asked to pay 20% coinsurance for the knee arthroplasty. The knee arthroplasty falls within the Outpatient Surgery Services benefit category. The record shows this surgery was never scheduled for 2021. 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 upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for the knee arthroplasty provided on December 21, 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 26,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that the charges are too
high for a telehealth visit with a nurse practitioner. 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 $25
copayment for each specialist visit.
You have been asked to pay a $25 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 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on November 10, 2020.
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this testing is a covered benefit and medically necessary. The Plan denied your request. The Plan says this service does not meet Medicare's criteria of medically necessary and reasonable and cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that non-coverage of the CxBladder assay coded 0013M has been reaffirmed by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder testing have not been met. Specifically, per Medicare, this testing is a non-covered service. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0013M) provided on November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft at time of implant placement (D6104), surgical removal of residual tooth roots (D7250), and surgical placement of implant body: endosteal implant (D6010) provided on November 20, 2020 by an OON provider.
You asked the Plan to pay for the bone graft, surgical removal of residual tooth roots, and endosteal implant. You say that you would like these services to be covered in full. The Plan denied your request. The Plan says the bone graft at time of implant placement (D6104) is not a covered benefit. The Plan also says that you are responsible for a 50% coinsurance for major dental services, and can be charged more when receiving care from an OON 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, bone graft at time of implant placement (D6104) is not among those covered under this benefit. The contract also says that you must pay a 50% coinsurance for major dental services, plus the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the bone graft at time of implant placement (D6104), surgical removal of residual tooth roots (D7250), and surgical placement of implant body: endosteal implant (D6010) provided on November 20, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on September 28, 2020.
You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration because the services provided were medically necessary. The Plan denied your request. The Plan says this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. We find that CPT code 95999 is not supported in the record. Specifically, train of four monitoring is considered integral to the primary neuromonitoring procedure and not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on September 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the pelvis with 3D rendering.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show rising of PSA after surgery or medical treatment.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, you have benign prostatic hypertrophy with lower urinary tract symptoms. You have had two negative biopsies. The MRI is requested to delay a repeat biopsy. The indicated reason for the use of MRI is not sufficiently substantiated in the literature to be considered medically reasonable and necessary as defined by Medicare rules. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the pelvis with 3D rendering.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home ventilator provided from November 23, 2020 and December 22, 2020.
You asked the Plan to waive the coinsurance for the home ventilator. You say that you are on a lot of medication and paying other bills. You say that you cannot afford to pay the cost. 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 20% coinsurance for Medicare-covered durable medical equipment and related supplies and any additional cost-sharing. You have been asked to pay $143.25, which is less than the standard 20% coinsurance for the home ventilator. The home ventilator falls within the "Durable medical equipment (DME) 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 home ventilator provided from November 23, 2020 and December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasounds provided from September 17, 2020, to September 24, 2020.

You asked the Plan to pay for the ultrasounds (97035). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the ultrasounds are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the ultrasounds provided from September 17, 2020, to September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a Freestyle Libre therapeutic continuous glucose monitor. You say that this item is medically necessary. The Plan denied your request. The Plan says coverage criteria for the therapeutic continuous glucose monitor have not been met.

The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided on September 19, 2019.

You asked the Plan to waive the copay for the services provided. You say that you were in constant pain. 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 $90 copay for emergency care. 

You have been asked to pay a $90 copay for the services provided. The services fall within the emergency 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 copay for the emergency room services provided on September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 20, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says insufficient information was submitted.

The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session, 60 minutes (90837) provided on September 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you have rendered treatment in good faith that the service will get reimbursed. The enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 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 individual psychotherapy session, 60 minutes (90837) provided on September 23, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral periapical x-rays, single image (D0220) and additional image (D0230) provided on December 31, 2020.

You asked the Plan to pay for the x-rays. You say that this denial is incorrect as you are covered for dental x-rays. The Plan denied your request. The Plan says the specific x-rays you received are not covered by Medicare or by the Plan's supplemental dental benefit.

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 intraoral periapical x-rays, single image (D0220) and additional image (D0230) provided on December 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on September 22, 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 assistant surgeon services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 26055. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for these services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services rendered on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital clinic visit provided on December 2, 2020.
You asked the Plan to waive the copayment for clinic visit. You say that according to the booklet explaining your benefits, your copayment for seeing any specialist is $45. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $325 copayment for outpatient hospital clinic visit. You have been asked to pay the allowed amount of $125.62, which is less than the $325 copayment for clinic visit. Clinic visit 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 copayment for an outpatient hospital clinic visit provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on June 15, 2020.

You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the item billed is not payable.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number. Also, the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis provided on June 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the room charge, pharmacy, and laboratory services provided on June 1, 2019, and June 2, 2019.
You asked the Plan to pay for the room charge, pharmacy, and laboratory services. You say that the diagnosis is not related to the enrollee's terminal illness. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 room charge, pharmacy, and laboratory services provided on June 1, 2019, and June 2, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided on August 17, 2020.

You asked the Plan to pay for the personal care services. You say that the provider was not notified that the contract had changed. You also say that the provider was not notified that the authorization had ended. The Plan denied your request. The Plan says personal care services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the personal care services provided on August 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on January 21, 2021.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered.
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 first intraoral periapical x-ray provided on January 21, 2021.