Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the mammogram.

You asked the Plan to waive the copayment for the mammogram. You say that you thought mammograms were covered in full. The Plan denied your request. The Plan says that this copayment was charged correctly.

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 pay a $0 copayment for screening mammograms.

The Plan says you must pay a $50 copayment for the mammogram because it was performed in a specialist's office. We do not find this argument persuasive. The claim for this mammogram explicitly states that this test was ordered for screening purposes (it was billed with a screening diagnosis code of Z12.31). In addition, the bill sent to you by the provider states this was a screening mammogram. Based on the Plan contract, you cannot be asked to pay more than $0 copayment for screening mammograms. Because this was a screening mammogram, it was not appropriate for the Plan to charge a $50 copayment. Therefore, we decided that the Plan has to waive the copayment for the mammogram.

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 pre-approve Magnetic Resonance Imaging (MRI) of the brain to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve MRI. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this MRI can be performed by an in-network provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the brain to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you would like reconsideration because inpatient admission is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expects that the member's necessary hospital care (including earlier ED and/or observation care) will span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from dialysis to
residence provided on May 11, 2020.

You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this
claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or
recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained
personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee
could have been safely transported by another type of vehicle. You did not request prior authorization. Based
on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport
have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance
transport from dialysis to residence provided on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (69210, 82948) provided June 29, 2020.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the CPT codes billed.

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 codes 69210 and 82948 are Removal, Cerumen, requiring
instrumentation, unilateral and Glucose; blood, reagent strip.

We find that CPT codes 69210, & 82948 are not supported in the medical record. Specifically, the record
shows that the cerumen removal was performed using lavage and not instruments. The record shows the
glucose testing was performed with a venous draw and not a reagent test strip. Based on this information, we
decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided
that the Plan does not have to pay for physician services (69210, 82948) provided June 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair van transportation.

You asked the Plan to pre-approve wheelchair van transportation. You say that the transportation service is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit under your plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pre-approve are wheelchair van transport services. Therefore, we decided that the Plan does not have to pre-approve wheelchair van transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) and two gingival irrigations (D4921 x2), and pay more for the maxillary immediate denture (D5130), four simple extractions (D7140 x4), five surgical extractions (D7210 x5), and periodontal maintenance (D4910).

You asked the Plan to pay for the removable prosthodontic procedure and gingival irrigations, or pay more for the maxillary immediate denture, extractions, and periodontal maintenance. You say that you believe these services should be covered. The Plan denied your request. The Plan says the removable prosthodontic procedure and gingival irrigation are not covered services. You were charged correctly for the maxillary immediate denture, extractions, and periodontal maintenance.

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 unspecified removable prosthodontic procedure and gingival irrigation are not among those covered under this benefit. The Plan contract lists periodontal maintenance (D4910) and maxillary immediate denture (D5130) as covered benefits, and you are responsible for a 70% coinsurance for each service. The contract also lists simple extraction (D7140) and surgical extraction (D7210) as covered benefits, and you are responsible for a 50% coinsurance for each extraction. The record also shows that you did not contact the Plan prior to these dates of service to verify your benefits. Therefore, we decided that the Plan does not have to pay for the removable prosthodontic procedure (D5899) and two gingival irrigations (D4921 x2), and pay more for the maxillary immediate denture (D5130), four simple extractions (D7140 x4), five surgical extractions (D7210 x5), and periodontal maintenance (D4910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination (92014).

You asked the Plan to waive the copayment for an eye examination. You say that nothing was done for you at the office visit, and you would like the Plan to waive the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

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 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 $45 copayment for an eye examination.

You have been asked to pay $45 for an eye examination. This service falls within the vision 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.

Your complaint about the physician not being able to help you and referring you to another provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder Detect (0012M) provided on October 14, 2020.

You asked the Plan to pay for the CxBladder Detect. You say that you would like reconsideration because this
testing is medically necessary. The Plan denied your request. The Plan says this testing is not covered by
Medicare.

The Plan must follow Medicare rules. Medicare rules say that CxBladder assay coded as 0012M, non-coverage
was 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 Detect have not been met. Specifically, this testing is not a Medicare covered
benefit. Therefore, we decided that the Plan does not have to pay for CxBladder Detect (0012M) provided on
October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 3, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with your internal medicine doctor.

You asked the Plan to waive the copayment for the office visit. You say that you should not have a copayment for this visit because it was your annual wellness visit. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for primary care visits.

The medical records from this date of service show that you did receive an annual wellness visit, but you also had an evaluation for your hypertension condition including diet and medication review. The records show that You have been asked to pay a $10 copayment for the office visit. The office visit falls within the primary care 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 the office visit you had with your internal medicine doctor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical
x-ray, and two additional intraoral periapical x-rays provided on November 5, 2020, by an OON provider.

You asked the Plan to pay for the comprehensive oral evaluation and intraoral periapical x-rays. You say that
you were misled as to what services were covered under your plan. The Plan denied your request. The Plan
says these services were rendered by an OON provider. The Plan also says that services performed by an OON
provider are not covered because your healthcare plan does not have OON benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received OON. The record shows that during your call with the Plan on August 31,
2020, you were given no misinformation. You were given the names of two dentists who were in-network with
your plan, and the address of the in-network office where these provider practice. Therefore, we decided that
the Plan does not have to pay for the comprehensive oral evaluation, first intraoral periapical x-ray, and two
additional intraoral periapical x-rays provided on November 5, 2020, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation mileage (A0170).

You asked the Plan to provide coverage for additional routine transportation mileage. You say that you need additional transportation since you are at a temporary address. The Plan denied your request. The Plan says the distance requested is not covered under your benefits.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving distance. 

We looked at your request, the records in the case file, and the rules. The requested transportation is greater than the Plan's limit of 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation mileage (A0170).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from April 16, 2020, through May 18, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while the enrollee is a member of our plan the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided from April 16, 2020, through May 18, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services rendered on December 6, 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 the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that PT services must be billed with the -GP modifier. 

We looked at the file and Medicare rules. The file shows that the provider did not bill the PT services with the required -GP modifier. Based on this information, we decided that Medicare rules for coverage of these services have not been met. You may wish to ask the provider to submit a corrected claim to the Plan. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services rendered on December 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hernia repair surgery provided at the in-network benefit level.

You asked the Plan to reimburse you for the hernia repair surgery at the in-network benefit level. You say that The Plan denied your request. The surgery you had in Arizona was elective and not due to an emergency. There was care available with an in-network provider in Minnesota, therefore we have upheld the decision to pay services in-network.

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 reimburse you 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 service at issue. We found no exception that would require the Plan to reimburse you for these services. Therefore, we decided that the Plan does not have to reimburse you for hernia repair surgery provided at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye examination (92012, 82134, 99199, 92081) provided on October 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an eye examination. You say that you were not aware that you had to use an in-network provider. The Plan denied your request. The Plan says services were received from an out-of-network provider and prior authorization was not 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 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 an eye examination (92012, 82134, 99199, 92081) provided on October 19, 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 complete series of intraoral x-rays.

You asked the Plan to pay for the complete series of intraoral x-rays. You say that the office told you that this service should 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. Bitewing x-rays are the only type of x-rays that are covered under your plan. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee.

You asked the Plan to pay for inpatient hospital care. You say that the claim was filed timely. The Plan denied your request. The Plan says the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for inpatient hospital care was not filed until November 3, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee.