Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services provided from May 24, 2020, to May 29, 2020.You asked the Plan to waive the copayment forthe inpatient hospital services. You say that you had previously met your out-of-pocket maximum for 2020.The Plan denied your request. The Plan says the out-of-pocket maximum had not been met and the cost share applied correctly 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 a $285 copayment each day for days 1 to 6 with a $0 copayment for each additional day for inpatient hospital care. You have been asked to pay a total cost share of $1425 for the inpatient hospital care ($285 copayment x 5 days). The services fall within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient hospital services provided from May 24, 2020, to May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for 3 simple extractions (D7210), the initial 15
minutes of deep sedation (D9222), the additional 15 minutes of deep sedation (D9223), and the unspecified
preventive service (D1999) provided on June 23, 2020.
You asked the Plan to pay the full amount for the dental services. You say that you are a widow with a very
limited income. You say that you had teeth that broke off at the gums. You say that your dentist chose this
surgical center to provide the services. You say that you did not have a choice because of the pandemic. The
Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says
that the payment cannot be made for dental services that you receive from a provider who 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 the provider who
has opted out of the Medicare program. The record shows that you signed a Medicare Opt Out form where you
acknowledged that the services would be your responsibility. Therefore, we decided that the Plan does not have
to pay the full amount for 3 simple extractions (D7210), the initial 15 minutes of deep sedation (D9222), the
additional 15 minutes of deep sedation (D9223), and the unspecified preventive service (D1999) provided on
June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 24, 2019.You asked the Plan to pay forthe services provided. The Plandenied your request. The Plan says the claim was not received timely per guidelines.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 valid and clean claim for the services provided was not filed until September 1, 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 forthe medical services provided on March 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on August 13, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you asked the doctor to clip all your nails and calluses, but he only clipped one nail. You say that this is unacceptable, and you want your copayment back.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each Medicare-covered visit.You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Podiatry Services" benefit category. The records show that you were treated during the visit. 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 forthe office visit provided on August 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefunctional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (CPT Code E0770).You asked the Plan to pre-approvethe DME. You say that the DME is necessary.The Plan denied your request. The Plan says the DME is not necessary.We asked our physician reviewer to carefully review the case file and apply the relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer found the patient has MS diagnosis. Criteria for stimulator not met as there is no spinal cause for the weakness.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 DME have not been met.Therefore, we decided that the Plan does not have to pre-approvefunctional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified (CPT Code E0770).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forinfusion services provided to the enrollee from May 15, 2020, to May 21, 2020 and billed under codes S9502 and S9500.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare guidance says procedure codes S9502 and S9500 have a status code of "I". Medicare guidance says status code "I" is defined as "Not valid for Medicare purposes. Medicare uses another code for reporting ofand payment for these services". The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codes. Medicare uses another set of codes for reporting of these services. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay forinfusion services provided to the enrollee from May 15, 2020, to May 21, 2020 and billed under codes S9502 and S9500.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on July 2, 2020 and billed under codes 51785-26 and  95886-26. You asked the Plan to pay forthese services. You say that this claim should be paid.The Plan denied your request. The Plan states that the medical records provided do not support the services described by these codes were rendered or that the number of units billed were provided. The Plan statesthe operative notes are incomplete. The Plan states According to (CPT) code definitions and guidance, codes 51785-26 and 95886-26 were inappropriately billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and provide medical records to support the services billed. In this case, review of the medical records show the documentation provided is incomplete and does not support the claim billed. Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on July 2, 2020 and billed under codes 51785-26and 95886-26.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing with CPT code G0483 provided. 
 
You asked the Plan to pay for CPT code G0483. You say that the medical records support the billing of CPT 
code G0483. The Plan denied your request. The Plan says the medical records do not support the billing of CPT 
code G0483. 
 
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 G0483 is Drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain 
evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we 
decided that Medicare rules for coverage of CPT code G0483 have not been met. Therefore, we decided that 
the Plan does not have to pay for the drug testing with CPT code G0483 provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordurable medical equipment provided on July 28, 2020 by an out of network (OON) provider.You asked the Plan to pay fordiabetic shoe inserts. You say that you are trying to be proactive.The Plan denied your request. The Plan says there are multiple in-network providers available for these services. The Plan says that 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 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 fordurable medical equipment provided on July 28, 2020 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from June 25, 2020, through June 30, 2020.You asked the Plan to waive the copayment forthe inpatient stay. You say that you were discharged too soon and ended up back in the hospital. You say that you shouldn't be liable.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per admission at an in-network provider. You have been asked to pay a $250 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient stay provided from June 25, 2020, through June 30, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forarthrocentesis, aspiration and/or injection (20610) hospital outpatient clinic visit (G0463) methylprednisolone acetate injection (J1030) provided July 01 , 2020.You asked the Plan to waive the copayment forthe outpatient clinic visit. You say that you are questioning how that can be considered outpatient surgery when the shot was done right in his office and total time of 15 minutes.The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $250 for each Medicare covered ambulatory surgical center visit for Outpatient surgery. You have been asked to pay $250 for each Medicare covered ambulatory surgical center visit for the outpatient clinic visit. the outpatient clinic visit falls within the Outpatient surgery 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 forarthrocentesis, aspiration and/or injection (20610) hospital outpatient clinic visit (G0463) methylprednisolone acetate injection (J1030) provided July 01 , 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mental health services provided by an out of network (OON) provider. 
 
You asked the Plan to pay for the mental health services. You say that no other doctor has helped you as much 
as this out-of-network doctor. The Plan denied your request. The Plan says unauthorized, non-plan care is not 
covered. This provider is not a Plan provider and you never requested prior authorization to see this doctor.  
 
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 
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 mental health services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spinal Neuroelectrodes (63650).

You asked the Plan to pre-approve the Neuroelectrodes. You say that the stimulator is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.

The Plan follows Medicare rules. Medicare rules say that Spinal Cord Stimulators are covered when medically necessary.

We asked our physician reviewer toc arefully 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 Neuroelectrodes. Our reviewer says that the requested neuroelectrodes are not medically necessary. Our physician reviewer found the records provided for review did not demonstrate that the enrollee has a diagnosis for which Medicare covers a spinal 
cord stimulator.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 Neuroelectrodes have not been met.Therefore, we decided that the Plan does not have to pre-approve Spinal Neuroelectrodes (63650).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for arthrocentesis provided.

You asked the Plan to waive the co payment for arthrocentesis. You say that 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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 co payment for outpatient surgery,including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received arthrocente. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $260.07, which is less than the $300 co payment. 

You have been asked to pay $260.07 for arthrocentesis. Arthrocentesis 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 co payment for arthrocentesis provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210) provided.

You asked the Plan to pay for the extraction. You say that you were advised by a plan representative that the provider in this case participates with your insurance. You say that you paid for the extraction out of pocket. You also say that you want your insurance to pay this bill.The Plan denied your request. The Plan says the provider in this case does not participate with your Dental Plan. The Plan says that you must use a participating dentist to utilized covered benefits. The Plan also says you were charged a reduced specialist rate for the services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the dental provider in this case was not in the Dental Plan's network. Dental services must be received by a participating dental provider in order to be covered. The record shows that the Plan confirmed that the list of participating dental providers did not include the provider in this case.Therefore, we decided that the Plan does not have to pay for the extraction (D7210) provided.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on July 26, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you said that you had to call 
the ambulance because of Covid-19. 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 $125 
copayment for ambulance services.  
 
You have been asked to pay a $125 copayment for ambulance services. Ambulance services falls within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided by a participating provider on July 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe application of desensitizing resin (D9911 x 2) provided on July 28, 2020.You asked the Plan to pay forthe dental service. You say that the dentist gave you an itemized invoice indicating that all of the services you needed would be covered by insurance.The Plan denied your request. The Plan says application of desensitizing resin is not listed as a covered service. The Plan says that you signed a treatment plan that shows the charges for the application of desensitizing resin were not covered and you would be responsible for the charges.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 forthe application of desensitizing resin (D9911 x 2) provided on July 28, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for retainer crowns (D6740) and a porcelain/ceramic pontic 
(D6245) received on June 16, 2020. 
 
You asked the Plan to pay for retainer crowns and a porcelain/ceramic pontic. You say that you were 
misinformed about the cost of these services. The Plan denied your request. The Plan says rules for payment 
have not been met. 
 
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 retainer 
crowns (D6740) and a porcelain/ceramic pontic (D6245) received on June 16, 2020.  
 
Your complaint about receiving erroneous or misleading information about your benefits from a representative 
of the 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.