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

We decided that the Plan does not have to pay for radiologic examination, hip, unilateral (73502) provided August 18, 2020.

You asked the Plan to pay for the diagnostic service. You say that the provider is in network with the plan, and you paid your copay. You spoke to the provider's office and they couldn't understand why the Plan did not pay. You are on a fixed income and hope the Plan helps you with these bills. The Plan denied your request. The Plan says there is another insurance policy that is the primary payer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers.

Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another insurance carrier that is primary. As the secondary insurer, the Plan cannot be held responsible for the diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for radiologic examination, hip, unilateral (73502) provided August 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on
January 12, 2021.

You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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, we have confirmed that code 99284
for the emergency department visit has a bundled relationship with code 99285 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 emergency department visit
coded 99284 provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection procedure you received on January 27, 2021.

You asked the Plan to waive the copayment for the epidural injection procedure. You say that you do not have to pay for the injection you received. You said that you were in an office and should only have a $15 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The services were rendered at an outpatient hospital facility.

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 outpatient surgery and services rendered in an outpatient hospital setting.

You have been asked to pay a $100 copayment for the epidural injection procedure. Records show that these services were performed at a pain management center that is part of an outpatient hospital facility. The epidural injection procedure falls within the outpatient surgery and services rendered in an outpatient hospital setting 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 epidural injection procedure you received on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on April 6, 2021 by an out of network (OON) provider.
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 services were rendered by an out-of-network provider without prior authorization.
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 the telehealth services provided on April 6, 2021
by an out of network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a
participating provider on March 19, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this
copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $25
copayment for physician/practitioner services/specialists.

You have been asked to pay a $25 copayment for a specialist office visit. The correct copayment has been
applied to the specialist office visit that was provided. A specialist office visit falls within the
physician/practitioner services/specialists 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 specialist office visit provided by a participating provider on March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive pulmonary screening panel (81223, 81302,
81330, 81345, 81406, 81407, 81408, 81479) provided on October 6, 2020.
You asked the Plan to pay for a comprehensive pulmonary screening panel. You say that this was medically
necessary. The Plan denied your request. The Plan says this was a screening service.
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 comprehensive pulmonary screening 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 a comprehensive pulmonary screening panel (81223, 81302, 81330, 81345, 81406,
81407, 81408, 81479) provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on March 8,
2021.
You asked the Plan to waive the copay for the specialist visit. You say that your Covid shot messed up your
shoulder. The Plan denied your request. The Plan says 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 $45
copay for each specialist visit for Medicare-covered services.
You have been asked to pay a $45 copay for the specialist visit. The copay is not determined by the quality of
care or outcome of previous services. The visit falls within the physician 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 copay for the specialist office visit provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive mechanical ventilator (E0466).

You asked the Plan to pre-approve a non-invasive mechanical ventilator. You say that the service is medically necessary. The Plan denied your request. The Plan says ventilators used to provide CPAP or bi-level PAP therapy are not covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 a non-invasive mechanical ventilator. Our reviewer says that the item is not medically necessary. Our physician reviewer found you may benefit from nocturnal ventilatory support, but a BiPAP device should be sufficient for your needs. Certain BiPAP devices can provide the AVAPS mode of ventilation that has been ordered, at less cost than a ventilator. Medicare does not cover a ventilator when it is used to provide BiPAP therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-invasive mechanical ventilator have not been met. Specifically, ventilators used to provide BiPAP therapy are not covered by Medicare or your Plan. Therefore, we decided that the Plan does not have to pre-approve a non-invasive mechanical ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. Transfer to a lower level of care may be considered when treatment has completed. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composites - one surface, anterior (D2330) (x2) and resin-based composite - two surfaces, anterior (D2331) provided February 19, 2021.

You asked the Plan to pay for the three fillings. You say that your dentist said you would only pay $45 per filling. The Plan denied your request. The Plan says a one-time exception has been allowed to process the claims as in-network. There is a limit of two fillings per calendar year which has been exceeded and thus 3 fillings are 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. The Plan covers the three fillings when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. The Plan provided documentation showing that 2 fillings have been covered by the Plan, one on February 12, 2021 and one on February 19, 2021. Based on this information, we determined that frequency limits have been exceeded. Therefore, we decided that the Plan does not have to pay for the resin-based composites - one surface, anterior (D2330) (x2) and resin-based composite - two surfaces, anterior (D2331) provided February 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination, knee (73562) provided February 19, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you received a bill for $15. You have already paid $40 for the doctor's office visit and you do not understand why you have to pay so much money. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $15 copayment for x-rays.
You have been asked to pay $15 copayment for the diagnostic service. The diagnostic service 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 the radiologic examination, knee (73562) provided February 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210), and fillings (D2391, D2392) provided from March 10, 2021, through March 22, 2021.

You asked the Plan to pay for an intraoral complete series of radiographic images, and fillings. You say that you were not aware what services were covered and the provider should have informed you. The Plan denied your request. The Plan says the services at issue are not covered 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 among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210), and fillings (D2391, D2392) provided from March 10, 2021, through March 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 26, 2021,
to February 9, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says SNF care
beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from September 9,
2020, to January 25, 2021. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing services provided from January 26, 2021, to February
9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 1, 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 services are 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 October 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on December 22, 2020.

You asked the Plan to waive the copayment for specialist services. You say that all you had was the procedure. You say that this visit had no other consultations. The Plan denied your request. The Plan says the correct copayment has been applied.

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 physician/practitioner services/specialist. 

You have been asked to pay a $30 copayment for specialist services. The correct copayment has been applied to the surgery that was provided by a specialist. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and deductible for an outpatient hospital primary care physician visit provided by a participating provider on January 4, 2021.

You asked the Plan to waive the copayment and deductible for an outpatient hospital primary care physician visit. You say that you are being incorrectly charged. You say that this was an annual wellness exam. The Plan denied your request. The Plan says the correct charges have been applied.

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 $10 copayment for physician/practitioner services/in-network/PCP and a $1,250 deductible for outpatient hospital services/outpatient hospital facility. 

The item or service you asked the Plan to waive the copayment and deductible for falls within the benefit category physician/practitioner services/in-network/PCP visit and outpatient hospital services/outpatient hospital facility. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $10 copayment for physician/practitioner services/in-network/PCP visit and a $1,250 deductible for an outpatient hospital services/outpatient hospital facility. This cost sharing is a contractual obligation that had not been met at the time an outpatient hospital primary care physician visit was received on January 4, 2021. The total amount you are being asked to pay is $43 ($10 + $33 = $43). When you see a physician in a hospital-based practice, physician and hospital charges are billed separately. Therefore, we decided that the Plan does not have to waive the copayment and deductible for an outpatient hospital primary care physician visit provided by a participating provider on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the mandibular partial denture (D5214) provided on December 7, 2020.

You asked the Plan to pay for the mandibular partial denture. You say that you were advised that this provider does not accept Medicare. The Plan denied your request. The Plan says that the service was rendered by a Medicare opt out provider. The Plan also says that you were advised that this provider does not accept Medicare, and you chose to continue with the service.

The Plan must follow Medicare rules. Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 

The record shows that you received a mandibular partial denture, and the EOC says you have up to a $2,000 allowance for supplemental preventive and comprehensive services every year. The EOC does not clearly state that services rendered by a Medicare opt out provider will not be covered. You reasonably believed this service would be covered under your $2,000 dental allowance because you saw a licensed dental provider. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the mandibular partial denture have been met. Therefore, we decided that the Plan has to pay for the mandibular partial denture (D5214) provided on December 7, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.