Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for individual psychotherapy, 45 minutes (90834) provided September 15, 2020.
You asked the Plan to waive the copayment for the psychotherapy services. You say that you were told that the provider was in in network. You never would have agreed to an appointment. You were told there was no copay. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the Evidence of Coverage.
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 50% of the Medicare allowed amount for each Medicare covered individual or group therapy visit.
You have been asked to pay $41.36 for the psychotherapy services. The psychotherapy service falls within the Outpatient mental health 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 individual psychotherapy, 45 minutes (90834) provided September 15, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on October 1, 2020.
You asked the Plan to pay for genetic testing. You say that no basis exists for the Plan to deny coverage of biomarkers explicitly covered under its policies and fail to extend coverage to additional biomarkers. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing is experimental/investigational.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided on May 6, 2020.

You asked the Plan to pay for secondary closure of surgical wound (13160) and debridement of skin, subcutaneous tissue (11004). You say that the Plan should pay this claim. The Plan denied your request. The Plan says assistant at surgery services for these codes are not payable.

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 13160 and 11004. 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 secondary closure of surgical wound (13160) and debridement of skin, subcutaneous tissue (11004) have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided on May 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan provided on June 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior authorization was not obtained as required.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the duplex scan provided on June 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 7, 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 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 on December 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480) provided on January 8, 2021 by an out of network (OON) provider.

You asked the Plan to pay for OON drug testing. You say that this service was provided in good faith. The Plan denied your request. The Plan says this service was 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 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 drug testing (G0480) provided on January 8, 2021 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a Computed Tomography (CT) scan, Fluorodeoxyglucose imaging contrast materials, fluoroscopic guidance, a catheter port, surgical trays, and injection of midazolam (a Medicare Part B drug) provided on December 23, 2020 and December 24, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $150 co-payment for CT scan, 20% coinsurance for imaging and medical supplies, $25 co-payment for fluoroscopic guidance, and 20% coinsurance for Part B drug.

Your total cost-sharing responsibility is therefore $231.75.

You have been asked to pay $150 co-payment for CT scan, 20% coinsurance for imaging and medical supplies, $25 co-payment for fluoroscopic guidance, and 20% coinsurance for Part B drug. CT scan, imaging supplies, fluoroscopic guidance, medical supplies, and Part B drug fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Medicare Part B Prescription Drugs" benefit categories. 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 cost-sharing for a Computed Tomography (CT) scan, Fluorodeoxyglucose imaging contrast materials, fluoroscopic guidance, a catheter port, surgical trays, and injection of Midazolam (a Medicare Part B drug) provided on December 23, 2020 and December 24, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Alimta for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says that the off-label use of this drug for the enrollee's condition is not medically accepted.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found vaginal cancer is treated the same as cervical cancer. The use of this drug is supported by the major drug compendia.

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 drug have been met. Therefore, we decided that the Plan has to pre-approve Alimta for the enrollee.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) received December 30, 2020 received from a non-participating provider.
You asked the Plan to pay for the determination of refractive state. You say that your quality of life will be diminished without the eye refraction. The Plan denied your request. The Plan says refractive services are not covered under your benefit plan unless rendered by a Routine Vision Care Provider found in the Routine Vision Care section of the Plan's Provider Directory.
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 performed during a routine exam performed by a Plan Routine Vision Care Provider. We looked at the file and the Plan's rules. There services were not rendered by a Routine Vision Care Provider. Based on this information, we decided that the Plan's rules for coverage of the determination of refractive state have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) received December 30, 2020 received from a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient telemedicine specialist visits provided on January 21, 2021, and February 10, 2021.

You asked the Plan to waive the co-payment for outpatient telemedicine specialist visits. You say that you believed you would not be charged for telemedicine visits. The Plan denied your request. The Plan says the co-payment for these claims has processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist physician/practitioner services.

You have been asked to pay a total cost share of $80 for outpatient telemedicine specialist visits (2 specialist visits x $40 co-payment). These services fall within the specialist physician/practitioner 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 co-payment for outpatient telemedicine specialist visits provided on January 21, 2021, and February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 22, 2018, to November 23, 2018.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the out-of-network 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 50% coinsurance for out-of-network inpatient hospital care. 

You had an inpatient hospital stay from November 22, 2018, to November 23, 2018, at an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The total allowed amount is $242.96 and 50% of that is $121.48. 

You have been asked to pay the total coinsurance amount of $121.48 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from November 22, 2018, to November 23, 2018.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 24, 2020.

You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was not on hospice on this date of service. 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. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on September 10, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on September 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 17, 2020.
You asked the Plan to pay for the services. You say that the results of this type of testing allow physicians to most effectively make treatment decisions. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no coverage for all cardiovascular risk assessment panels, except the basic lipid panel. Panel testing is not specific to a given patient's lipid abnormality or disease. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nuclear medicine study of vessels of heart (78452) provided January 14, 2021.
You asked the Plan to waive the copayment for nuclear medicine study of vessels of heart. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the copayment has processed correctly, and no reimbursement is due.
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 outpatient hospital nuclear medicine services. You have been asked to pay a $275 copayment for nuclear medicine study of vessels of heart. This service falls within the outpatient hospital nuclear medicine 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 nuclear medicine study of vessels of heart (78452) provided January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the abdominal ultrasound provided on December 22, 2020.

You asked the Plan to waive the copay for the ultrasound. You say that the bill was too expensive. The Plan denied your request. The Plan says you are responsible for paying your share of the cost.

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 $125 copay for each Medicare-covered radiological diagnostic service. 

You have been asked to pay a $125 copay for the ultrasound. The ultrasound falls within the outpatient diagnostic tests 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 abdominal ultrasound provided on December 22, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for emergency care provided on November 23, 2020.
You asked the Plan to waive the copayment for emergency care. You say that the Plan did not pay anything toward the bill. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment or an $80 copayment for emergency care. The record shows that you qualify for Medicaid assistance. Therefore, you cannot be asked to pay a copayment for emergency care provided on November 23, 2020. The Plan says you must pay an $80 copayment for emergency care. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for emergency care. Therefore, we decided that the Plan has to waive the copayment for emergency care provided on November 23, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) scan of
arm (73218) provided January 5, 2021.
You asked the Plan to waive the copayment for MRI scan of arm. You say that you believe you are being
overcharged. The Plan denied your request. The Plan says the copayment has processed correctly, and no
reimbursement is due.
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 diagnostic radiology services.
You have been asked to pay a $150 copayment for MRI scan of arm. This service falls within the diagnostic
radiology 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 magnetic resonance imaging (MRI) scan of arm (73218) provided January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the periodic oral evaluation (D0120) and prophylaxis - adult (D1110) provided January 20, 2021 by an out-of-network (OON) provider.
You asked the Plan to provide additional payment for the dental exam and cleaning. You say that you feel you were given confusing information and the dental rider is a waste of money. The Plan denied your request. The Plan says since you received services OON, you are responsible for the difference between the allowed amount and the total amount charged by the 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. The Plan covers the dental exam and cleaning up to the Plan's allowed amounts for each service. We looked at the file and Medicare rules. In this case you received services from an OON provider. The Plan has provided payment for these services up to the Plan's allowed amount for each service. Since you used a dentist that does not participate in the Plan's dental vendor's network, the dentist can bill you for additional costs they have charged over the maximum payable benefit amount for services covered by the Plan. Based on this information, we decided that the Plan's rules for coverage of the dental exam and cleaning have not been met. Therefore, we decided that the Plan does not have to provide additional payment for the periodic oral evaluation (D0120) and prophylaxis - adult (D1110) provided January 20, 2021 by an out-of-network (OON) provider.