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

We decided that the Plan does not have to waive the copayment for a colonoscopy
You asked the Plan to waive the copayment for a colonoscopy. You say that rectal bleeding should not make the colonoscopy diagnostic 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 $500 copayment for each visit to an outpatient hospital facility. You received a colonoscopy on September 23, 2019. Due to the symptoms of rectal bleeding, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $500 copayment. You have been asked to pay a $500 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
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on July 22, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that the enrollee cannot afford the
charges. 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 $90 copayment for emergency care.
The enrollee has been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency
care 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 an ER visit provided on July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam you had on October 21, 2019.
You asked the Plan to waive the copayment. You say that you were told there would be no copayment. The Plan denied your request. The Plan says you are responsible for the cost share.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. Review of the file shows that you had an eye exam on October 21, 201. You have been asked to pay a $40 copayment for the exam. The exam falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the eye exam you had on October 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on November 1, 2019.You asked the Plan to waive the copayment for the ED visit. You say that you were onlyasked questions over a monitor. You say that you shouldn't owe the copayment.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 an $85 copayment for Medicare-covered emergency room visits.You have been asked to pay an $85 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were evaluated by the psychiatry coordinator. 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 ED visit provided on November 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
You asked the Plan to pre-approve bone marrow aspiration. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is experimental for use in spinal fusion surgery. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) and the re-treatment for a root canal (D3348) provided from July 19, 2018 to September 6, 2018 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you took the enrollee to an in network dental office and were advised that they no longer accepted the enrollee's plan. You say that the services were an emergency so you took her to your dental provider. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that authorization was not obtained before the enrollee received the services.
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, dental services that are received out of network with no prior authorization are not covered. Therefore, we decided that the Plan does not have to pay for the crown (D2750) and the re-treatment for a root canal (D3348) provided from July 19, 2018 to September 6, 2018 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for colpocleisis
You asked the Plan to waive the copayment for colpocleisis. You say that you were sent home and did not receive the procedure and 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 $250 copayment for outpatient hospital services. The medical records show that you received outpatient hospital services on October 28, 2019. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for colpocleisis. Colpocleisis falls 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 copayment for colpocleisis
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a zoster (shingles) vaccine (90750) and administration
(90471) provided on October 17, 2019.
You asked the Plan to pay for a shingles vaccine and administration. You say that this was medically
necessary. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of the
enrollee's Part D prescription drug Plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine
and administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine
and administration. Therefore, we decided that the Plan does not have to pay for a zoster (shingles) vaccine
(90750) and administration (90471) provided on October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device (33289).
You asked the Plan to pre-approve the CardioMEMs device. You say that the member's condition could cause health decline and rehospitalization. The Plan denied your request. The Plan says the efficacy of the CardioMems device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. The device should be considered investigational. 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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device (33289).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery services provided by from May 13, 2019 through May 14, 2019.
You asked the Plan to waive the coinsurance for outpatient surgery services. You say that your physician required you to stay overnight. You say that your fees should be waived. 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% of the total cost for each Medicare-covered service provided in an outpatient hospital or an ambulatory surgical center, including but not limited to hospital or facility charges, observation room/stay charges, physician charges and surgical charges. You have been asked to pay a total of $954.89 for outpatient surgery services. Outpatient surgery services fall 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 coinsurance for outpatient surgery services provided by from May 13, 2019 through May 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulatory blood pressure monitor (A4670).You asked the Plan to pay for the ambulatory blood pressure monitor. You say that this was a medically necessary claim.The Plan denied your request. The Plan says coverage criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that ABPM must be performed for at least 24 hours to meet coverage criteria and is only covered for those patients with suspected white coat hypertension. We looked at the file and Medicare rules. In this instance, there is no evidence of a diagnosis of white coat hypertension or monitoring for at least 24 hours. Based on this information, we decided that Medicare rules for coverage of the ambulatory blood pressure monitor have not been met.Therefore, we decided that the Plan does not have to pay for an ambulatory blood pressure monitor (A4670).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a hip x-ray (73502) provided on August 9, 2019.
You asked the Plan to pay for the hip x-ray. You say that per CMS, you are not allowed to bill globally. The Plan denied your request. The Plan says the providers that rendered the professional and technical components of this service have the same TIN. This code should be billed globally.
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 code 73502 is not supported in the medical record. Specifically, the provider rendered both the professional and technical components of this service. This means that CPT code 73502 should be billed globally and not with modifier 26. Based on this information, we decided that Medicare rules for coverage of the hip x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a hip x-ray (73502) provided on August 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on August 9, 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 procedure code 25600 is not supported.
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 25600 is closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation. We find that CPT code 25600 is not supported in the medical record. Specifically, there is no documentation of closed treatment of a distal fracture in the submitted records. 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 services rendered to the enrollee on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on June 10, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650) provided to the enrollee on June 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe air ambulance service provided on July 6, 2019.You asked the Plan to reimburse you forthe air ambulance transport.You say that the enrollee's critical illness was the reason the transport was imperative.The Plan denied your request. The Plan says the enrollee did not need a higher level of care therefore this transport was not necessary.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. We looked at the file and Medicare rules. The record shows the medical needs were being met at the facility in New York and it was your choice to have the enrollee transported back to your home state. Based on this information,we decided that Medicare rules for coverage of the air ambulance transport. have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe air ambulance service provided on July 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 23, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 80307 remains not supported.
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 80307 is "drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzer." We asked our coding 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 services at issue in this case were not coded correctly. Our coding reviewer found the medical records submitted contains a Confirmation Results Summary, however, there is no information provided as to what method(s) was used to arrive at these results. Therefore, there is not enough information provided to validate the services performed meet Medicare coverage criteria. We looked at this coder'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 drug testing services provided to the enrollee on October 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 4, 2019.

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says oral exams and prophylaxis are covered 2 times per plan year. The Plan also says that the frequency limit for these services have 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.

Though the Plan offers a dental benefit in excess of Medicare coverage and oral exam and prophylaxis are covered services, the frequency limits have been exceeded. The record shows that you received an oral exam and prophylaxis on March 14, 2019 and April 19, 2019 which the Plan processed and paid. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2 surgical extractions (D7140) and the removal of a
benign lesion (D7140) provided on October 21, 2019.
You asked the Plan to pay for the dental services. You say that you had to get a cyst removed which was
located underneath your teeth. You say that the procedure required an oral surgeon. You also say that per the
member benefits, services provided by an oral surgeon should be covered. The Plan denied your request. The
Plan says per the claim submitted, the services were not provided due to preparation for radiation therapy, a
kidney transplant or a heart valve replacement or that there is a need for jaw reconstruction due to injury.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for the 2 surgical extractions
(D7140) and the removal of a benign lesion (D7140) provided on October 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services
provided from November 1, 2019 through November 22, 2019.
You asked the Plan to waive the copayment for the SNF services. You say that you should not have to pay for
this because you told the facility you needed to be discharged on day 20. The Plan denied your request. The
Plan says that 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 $172
copayment per day for days 21-100 of Skilled nursing facility (SNF) care.
You have been asked to pay a $344 copayment for the SNF services. The SNF services fall within the days 21-
100 of Skilled nursing facility (SNF) 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 the skilled nursing facility (SNF) services provided from November 1, 2019 through November 22, 2019.