Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for educational supplies (99071) provided on August 19, 2019.
You asked the Plan to pay for the educational supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99071 is included in the payment of the other services performed on the same date of service, for the same patient and by the same provider and is not separately reimbursable.
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 99071 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99071 has a status code of B. This means that payment for this service is always bundled into the payment for other services. Based on this information, we decided that Medicare rules for coverage of the educational supplies have not been met. Therefore, we decided that the Plan does not have to pay for educational supplies (99071) provided on August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a CT scan provided on December 6, 2019.
You asked the Plan to waive the deductible for a CT scan. You say that you were assured by the provider that the test was covered. 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. Your contract with the Plan says that there is a $400 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received a CT scan on December 6, 2019. The record shows that you had paid $0 toward the $400 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $219.28. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time a CT scan was received on December 6, 2019 to December 27, 2019. Therefore, we decided that the Plan does not have to waive the deductible for a CT scan provided on December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for pulmonary rehabilitation provided from
November 1, 2019 to December 30, 2019.
You asked the Plan to waive the copayments for pulmonary rehabilitation. You say that you disagree with the
charges because you had only expected to pay $9 per each visit. The Plan denied your request. The Plan says
the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment for pulmonary rehabilitation services.
You received pulmonary rehabilitation from November 1, 2019 to December 30, 2019 for a total of 20 visits.
Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20
(copayment) x 20 (pulmonary rehabilitation services) = $400.
You have been asked to pay the total copayment amount of $400 for pulmonary rehabilitation. Pulmonary
rehabilitation falls within the pulmonary rehabilitation 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 pulmonary rehabilitation provided from November 1, 2019 to December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee arthroplasty provided on October 16, 2019 to October 18, 2019.
You asked the Plan to waive the coinsurance for the knee arthroplasty. You say that the Plan should pay the full claim. The Plan denied your request. The Plan says the coinsurance was charged 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% coinsurance for Outpatient Surgery and Other Medical Services. You have been asked to pay 20% coinsurance for the knee arthroplasty. the knee arthroplasty falls within the Outpatient Surgery and Other Medical 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 coinsurance for the knee arthroplasty provided on October 16, 2019 to October 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
You asked the Plan to pre-approve the ablation. You say that this is medically necessary. The Plan denied your request. The Plan says this is still being studied in clinical trials for efficacy in the treatment of knee pain due to osteoarthritis.
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 ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental and investigational procedure that is the subject of ongoing clinical trials. You are not in a clinical trial. Therefore, this request is deemed as not medically reasonable or necessary. 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 ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 2, 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 G0480 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 G0480 is definitive drug testing, 1-7 drug classes. We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation does not contain any lab results for testing of 1-7 drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on November 14, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were told that the enrollee would owe a $40 copayment for the office visit and disagree with the additional 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 20% coinsurance for Medicare Part B prescription drugs. The enrollee received a Medicare Part B drug on November 14, 2019. The allowed amount is $900 and 20% of that is $180. The enrollee has been asked to pay the total coinsurance amount of $180 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Powered Mobility Device (PMD) (K0739).
You asked the Plan to pre-approve the PMD. You say that the PMD is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that face-to-face encounter must be conducted within six (6) months prior to the order date of the PMD. We looked at the file and Medicare rules. The record does not include documentation of a face-to-face encounter reviewing the enrollee's mobility needs and functional abilities within the 6 months prior to the order for the PMD. Based on this information, we decided that Medicare rules for coverage of the PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Powered Mobility Device (PMD) (K0739).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 26, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for arthrocentesis provided on December 23, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with the fact you are being charged for an injection. 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 for each outpatient hospital facility visit for outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers. The Plan says you must pay a $10 copayment for arthrocentesis. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for each outpatient hospital facility visit for arthrocentesis. The record shows that services were provided in an outpatient hospital facility, not a specialist's office. Therefore, we decided that the Plan has to waive the copayment for arthrocentesis provided on December 23, 2019.
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 pay for diagnostic radiology services provided on December 17, 2019.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 diagnostic radiology services provided on December 17, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for Nivolumab provided on October 15, 2019.You asked the Plan to pay for Nivolumab (J9299). You say that this drug was medically necessary.The Plan denied your request. The Plan says that this drug was not approved.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 pay for Nivolumab (J9299). Our reviewer says that the drug was medically necessary. Our physician reviewer found Nivolumab is FDA approved for the treatment of locally advanced, metastatic, and unresectable melanoma. This enrollee has recurrent melanoma BRAF negative and Nivolumab would be a standard of care. The service is reasonable and medically necessary as well as safe and effective for this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nivolumab (J9299) have been met.Therefore, we decided that the Plan has to pay for Nivolumab provided on October 15, 2019.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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services provided from January 7, 2020 to January 31, 2020.You asked the Plan to waive the copayments for cardiac rehabilitation services. You say that you thought that you would only owe a $15 copayment.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 $30 copayment for cardiac rehabilitation services. You received cardiac rehabilitations services provided from January 7, 2020 to January 31, 2020 for a total of 11 services. Therefore, you are responsible to pay a $30 copayment per each date of service. The total amount you owe is: $30 (copayment) x 11 (cardiac rehabilitations services) = $330. You have been asked to pay the total copayment amount of $330 for cardiac rehabilitation services. Cardiac rehabilitation services fall within the cardiac rehabilitation 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 cardiac rehabilitation services provided from January 7, 2020 to January 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

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

We decided that the Plan does not have to pay for the drug testing rendered on June 21, 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 G0481 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 G0481 is definitive drug testing, 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. Specifically, there are no definitive lab results for 8-14 drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a duplex scan and an electrocardiogram (ECG) provided on January 15, 2020 and January 29, 2020.You asked the Plan to waive the copayments fora duplex scan and an ECG. You say that you feel that you should not be charged separate copayments because the tests were necessary.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 $45 copayment for diagnostic procedures and basic radiological services provided in a specialist's office.You received a duplex scan on January 15, 2020. Therefore, you are responsible to pay the $45 copayment. You received an ECG on January 29, 2020. Therefore, you are responsible to pay the $45 copayment. The total amount you owe is: $90.  You have been asked to pay the total copayment amount of $90 for a duplex scan and an ECG. A duplex scan and an ECG 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 fora duplex scan and an electrocardiogram (ECG) provided on January 15, 2020 and January 29, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 3, 2020.You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit 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 $10 copayment for primary care provider visits.The medical records show that you received services beyond an annual wellness visit. Therefore, you are responsible to pay the $10 copayment.  You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office 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 an office visit provided on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for supplies and materials (CPT Code 99070)
provided to the enrollee on February 28, 2019.
You asked the Plan to waive the copayment for the services. You say that no one told you anything about a
copay. The Plan denied your request. The Plan says the claim was processed accordingly with the member's
2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
This service is included in another service provided to the enrollee at the same time by the same physician. The
enrollee is not responsible for this amount. However, the member received care in a SNF, for which you are
disputing your responsibility for copayment amounts to the facility for dates of service of
January 8, 2019 through January 29,2019. The Plan's records indicate this provider is in-network with the
member's plan. The member's EOC, states that while inpatient in a SNF, days 1-20 bear a $0 copayment.
January 29, 2019 marked day 21, in which the EOC states that days 21-100 bear a $172 copayment per day.
This totals $172 for your claim. You are also disputing responsibility of copayment amounts to
the Provider for the dates of service of February 7, 2019 through February 18, 2019. These dates mark days 22-
33, for a total of 11 billable days with a copayment of $172 each day. This totals $1892 for your claim, although the facility is only billing for $1608.11. These copayments are your
responsibility. We are still unable to approve your request for removal of copayment responsibility to the Provider for care provided in a SNF. 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 supplies
and materials (CPT Code 99070) provided to the enrollee on February 28, 2019.