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

We decided that the Plan does not have to reduce the copayment for the eye procedure provided on October 7, 2019.
You asked the Plan to reduce the copayment for the eye procedure. You say that you were not told this was a surgical procedure. You say you thought there would be a $40 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment per date of service at an outpatient hospital facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $400 copayment for the eye procedure.
You have been asked to pay a $298.34 copayment for the eye procedure. The eye procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the eye procedure is considered a surgical procedure.
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 reduce the copayment for the eye procedure provided on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 1,2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on October 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services that you provided on May 20, 2019, July 22, 2019 and September 25, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan saysthat 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 the physician's services that you provided on May 20, 2019, July 22, 2019 and September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on February 18, 2020.You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are a duplicate.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 88305 is Level IV -Surgical pathology, gross and microscopic examination Abortion -spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy -without uterusLip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium -biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy.We find that CPT code 88305 is not supported in the medical record. Specifically, this was reported twice for the same date of service, once with modifier 26 or technical component and once without a modifier (global service) It is inappropriate to report a procedure as a global service and as the technical/professional components. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met.Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on February 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for diagnostic mammograms provided on February 19, 2020.
You asked the Plan to waive the copayments for diagnostic mammograms. You say that you disagree with the charges because you have a personal history of breast cancer and feel that the services should be considered preventative. 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 each basic imaging service. You received diagnostic mammograms on February 19, 2020. The mammograms are considered diagnostic due to your personal history of breast cancer. Therefore, you are responsible to pay a $20 copayment per each mammogram. The total amount you owe is: $40. You have been asked to pay the total copayment amount of $40 for diagnostic mammograms. Diagnostic mammograms fall within the outpatient hospital 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 diagnostic mammograms provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased December 7, 2019.
You asked the Plan to pay for the hearing aids. You say that you think you have jumped through enough hoops to meet the requirements that the Health Plan has for hearing aid coverage. You continue to see ads that say Medicare will cover hearing aids. The Plan denied your request. The Plan says hearing aids must be purchased from a TruHearing provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from the TruHearing provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased December 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on March 27, 2019.You asked the Plan to waive the copayment for lab services. You say that you disagree with the provider being considered an outpatient hospital facility and the labs were taken as part of an annual wellness exam.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for lab services provided in an outpatient hospital facility. The enrollee received lab services on March 27, 2019. Lab services are not included in an annual wellness visit. The record shows that services were provided at an outpatient hospital facility. Therefore, the enrollee is responsible to pay the $10 copayment. The enrollee has been asked to pay a $10 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for lab services provided on March 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 31, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 medical services provided to the enrollee by an out-of-network provider on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for eyeglasses provided on November 14, 2019.
You asked the Plan to reimburse you for the eyeglasses. You say that you should have been informed up front what vision providers you can go to in order to be reimbursed. The Plan denied your request. The Plan says vision services are only covered when received by a participating provider.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received by a participating provider.
We looked at the file and the Plan's rules. The file shows you received the eyeglasses from a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on August 28, 2019.
You asked the Plan to pay for the extraction. You say that you were told that if the provider was out-of-network, you would submit the claim and part of the cost would be covered. You also say that you are very limited in your area as to who will accept the Health Plan. The Plan denied your request. The Plan says this provider is not a participating provider with the Health Plan.The Plan also says that services need to be provided in-network to be eligible for payment.
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 covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the extraction provided on August 28, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the percutaneous vertebral augmentation(kyphoplasty)(22513) provided on January 30, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial as the service was medically necessary for the enrollee.The Plan denied your request. The Plan says that vertebral decompression by percutaneous vertebral augmentation of the nucleus pulposus is not a Medicare covered benefit for any use.The Plan follows Medicare rules. Medicare rules say that kyphoplasty is indicated for painful osteoporotic or osteolytic compression fractures of the thoracic or lumbar vertebrae.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 this service. Our reviewer says that this service was medically necessary for the enrollee. Our physician reviewer found that the enrollee has a diagnosis of collapsed vertebra, not elsewhere classified, thoracic region, sequela of fracture. She had severe, debilitating thoracic pain secondary to an acute/subacute compression fracture, that was unresponsive to nonoperative treatment modalities. According to Medicare rules, kyphoplasty is indicated for painful osteoporotic or osteolytic compression fractures of the thoracic or lumbar vertebrae.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have been met.Therefore, we decided that the Plan has to pay for the percutaneous vertebral augmentation (kyphoplasty) (22513) provided on January 30, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided on December 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for injection services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for injection services provided on December 18, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider from September 30, 2019to November 20, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says your passport benefits were no longer active.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 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 medical services provided to you by an out-of-network provider from September 30, 2019 to November 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.You asked the Plan to pre-approve Botox injections. You say that the enrollee needs this medication.The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 9, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you did not have time to find a network provider. The Plan denied your request. The Plan says your interactions were reviewed with the Health Plan and based on our findings, the Plan did not misrepresent the plan benefits, nor were you provided with any incorrect information verbally or in writing regarding the 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. The provider is not in-network and your EOC clearly states, services are only covered when received by a participating provider. Therefore, we decided that the Plan does not have to pay for the dental services provided on December 9, 2019 by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the brain (70552).You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.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 MRI is medically necessary. Our physician reviewer found NCCN guidelines suggest an MRI every 3 months after treatment for one year. The MRI is medically appropriate for surveillance.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 been met.Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the brain (70552).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 21, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 medical services provided to the enrollee by an out-of-network provider on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen concentrator purchased on July 2, 2019.
You asked the Plan to pay for the portable oxygen concentrator. You say that the doctor recommended the portable oxygen concentrator for ease of use outside of the home. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Although the provider recommended the portable oxygen concentrator Medicare rules states, only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for portable oxygen concentrator purchased on July 2, 2019.