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

We decided that the Plan does not have to waive the copayment for an EGD.

You asked the Plan to waive the copayment for an EGD. You say that you thought that you would not owe a copayment for a colonoscopy. 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 surgery, including services provided at hospital outpatient facilities.

You have been asked to pay a $250 copayment for an EGD. An EGD 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 an EGD.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visits.

You asked the Plan to waive the copayments for the urgent care visits. You say that you already paid when the services were provided and should not have to pay additional copayment. The Plan denied your request. The Plan says the copayments were 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 a $30 copayment for Medicare-covered urgently needed services.

You have been asked to pay a total of $60 ($30 copayment x 2 visits = $60) for the urgent care visits. You have already paid $5 per visit and therefore are being charged an additional $50 for a total cost share of $60. The urgent care visits fall within the Urgently needed 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 the urgent care visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (urothelial) gene expression profile testing with code 0012M provided on August 21, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is eligible for payment as long as the service meets medical necessity guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because test code 0012M is non-covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that oncology (urothelial) gene expression profile testing is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for oncology (urothelial) gene expression profile testing with code 0012M provided on August 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the Duplex scan of extracranial arteries (93880), Transcranial Doppler studies of the intracranial arteries (93892, 93886, 93890) and Testing of autonomic nervous system function (95923) provided September 22, 2020.
You asked the Plan to waive the copayments for the Duplex scan, Transcranial Doppler studies and Autonomic nervous system testing. You say that you were unaware of the copayments for the tests and the cost is too high. The Plan denied your request. The Plan says the copayments were 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 a $110 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic). The Plan contract also says that enrollees must pay a $25 copayment for Medicare-covered non-radiological diagnostic services. You have been asked to pay a total of $465 (($110 copayment x 4 radiological diagnostic tests) + $25 copayment for the non-radiological test = $465) for the Duplex scan, Transcranial Doppler studies and Autonomic nervous system testing. These services fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the Duplex scan of extracranial arteries (93880), Transcranial Doppler studies of the intracranial arteries (93892, 93886, 93890) and Testing of autonomic nervous system function (95923) provided September 22, 2020.
Appeal type: Outpatient Mental Health
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 September 15, 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 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 medical services provided to the enrollee by an out-of-network provider on September 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ECG's provided from October 21, 2020, to October 29, 2020.
You asked the Plan to waive the copayment for ECG's. You say that you disagree with the charges because you have paid into the Plan for years. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct the 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 $100 copayment for diagnostic procedures and tests. You received an ECG on October 21, 2020. Therefore, you are responsible to pay $50, which is less than the $100 copayment. You received an ECG on October 29, 2020. Therefore, you are responsible to pay $50, which is less than the $100 copayment. The total amount you owe is: $100. You have been asked to pay a $100 copayment for ECG's. ECG's fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ECG's provided from October 21, 2020, to October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on February 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services you received on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321) provided August 5, 2020.
You asked the Plan to pay for Guardant360 testing. You say that you are appealing the decision that Guardant360 is experimental and request reprocessing of the claim in-network since you are the only service provider for Guardant360. The Plan denied your request. The Plan says does not meet Medicare NCD/LCD requirements.
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, we find that the CPT codes are not supported in the medical record. Specifically, there is a more appropriate code to describe the services provided. To report a CGP service, test providers should use CPT code 81479. Providers must not unbundle the services described by a HCPCS/CPT code. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81310, 81311, 81314, 81321) provided August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no evidence of an established relationship between the member and the ordering physician.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the lab services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 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 psychotherapy services provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you feel that the first technician should have positioned you properly to avoid the second mammogram. 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 $99 copayment for diagnostic procedures and tests provided at any location other than a physician's office.

You have been asked to pay a $99 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic mammogram.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluid, pneumatic, or electronic/microprocessor knee (L5814, L5848) and a flex-walk system or equal (L5981) for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that the requested K3 components exceed the member's needs and cannot be covered.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The requested items exceed the patient's medical need as the physician and documentation does not support that this patient is a level K3 ambulator given the documentation that she used a single point cane prior to her amputation, uses a walker to ambulate, and a power wheelchair for distance mobility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a fluid, pneumatic, or electronic/microprocessor knee (L5814, L5848) and a flex-walk system or equal (L5981) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement and wound care services coded as 11043, 10140, 11042 and 97597.

You asked the Plan to pay for the debridement and wound care services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the records do not support the service 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.

We find that CPT code 11043 is not supported in the medical record. The records submitted did not include documentation of debridement of muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue, if performed). CPT code 10140 is not supported in the medical record. The records submitted did not include documentation of incision and drainage of hematoma, seroma or fluid collection. CPT code 11042 is not supported in the medical record. The records submitted did not include documentation of debridement of subcutaneous tissue (which includes epidermis and dermis) for the first 20 cm or less. CPT code 97597 is not supported in the medical record. The records submitted did not include documentation of removal of devitalized tissue from wounds, selective debridement, without anesthesia, wound assessment, topical applications, instructions for ongoing care, total wound surface area first 20 sq cm. May include scalpel, scissors, waterjet. The records show that multiple attempts were made to obtain the additional information from the provider. Based on this information, we decided that Medicare rules for coverage of the debridement and wound care services have not been met. Therefore, we decided that the Plan does not have to pay for the debridement and wound care services coded as 11043, 10140, 11042 and 97597.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the diagnostic mammogram, the breast
ultrasound, or the tomosynthesis.

You asked the Plan to reduce the copayments for the diagnostic mammogram, the breast ultrasound, and the
tomosynthesis. You say that the most you can pay is $40 as you are retired and do not have a lot of money.
The Plan denied your request. The Plan says you have been asked to pay 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 $50
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.

You have been asked to pay a $146.31 for the diagnostic mammogram, the breast ultrasound, and the
tomosynthesis. The diagnostic mammogram, the breast ultrasound, and the tomosynthesis fall within the
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. See chart provided.

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 copayments for the diagnostic mammogram, the breast ultrasound, and the
tomosynthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids.

You asked the Plan to reimburse you for the hearing aids. You say that you are requesting reconsideration of some partial reimbursement on the basis of having the discount program. The Plan denied your request. The Plan says hearing aid services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services.

Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to reimburse you for hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a tall adjustable walker (E0143).

You asked the Plan to pay for a tall adjustable walker. You say that the tall walker helps the enrollee's back and creates less strain on arms, wrists, and shoulders. The Plan denied your request. The Plan says rules for payment have not been met because the provider in this case is not enrolled in the Medicare program.

The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, the item at issue was provided by a provider that appears to not be certified for Medicare. The provider at issue did not come up on the Medicare.gov Supplier Directory search for durable medical equipment providers serving the enrollee's area. There was no documentation supplied by the provider to verify that they are certified by Medicare. Therefore, we decided that the Plan does not have to pay for a tall adjustable walker (E0143).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045.

You asked the Plan to pay for the x-ray 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 not separately payable.

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, we have confirmed that code 71045 for the x-ray services has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160).

You asked the Plan to pay for the dental service. You say that you went to the dentist because they are in network. You say that that dentist could not help you so they sent you to someone else. You say that your insurance would only pay $1,500 of the treatment plan of $6,000 to $10,000. You say that you cannot afford to go into that much debt at your age. You also say that you want to be taken off this plan for good as it does not help you. The Plan denied your request. The Plan says detailed and extensive oral evaluation is not listed as a covered service.

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 service that you received is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the detailed and extensive oral evaluation (D0160).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says there is no authorization on file for this service.

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 service 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 physician's services.