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

We decided that the Plan does not have to pay for the office visit and x-ray provided on August 11, 2020 by an
out of network provider.

You asked the Plan to pay for the office visit and x-ray. You say that it was an urgent care need. The Plan
denied your request. The Plan says you did not request prior authorization for the out-of-network 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 services at issue in this appeal. 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 the office visit and x-ray provided on August 11, 2020 by an out of network
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided on April 8, 2020.

You asked the Plan to pay for the therapeutic continuous glucose monitor. You say that the therapeutic continuous glucose monitor is helping the enrollee. The Plan denied your request. The Plan says the medical records document the enrollee takes insulin on an as needed basis.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood glucose testing results.

Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor provided on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from July 8, 2020, to August 12, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges above the $45 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 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs from July 8, 2020, to August 12, 2020, for a total of 6 services. The allowed amount per each drug is $140.50 and 20% of that is $28.10. The total amount you owe is: $28.10 (coinsurance) x 6 (drug services) =$168.60. 

You have been asked to pay the total coinsurance amount of $168.60 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided from July 8, 2020, to August 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagus biopsy provided on August
19, 2020.

You asked the Plan to waive the copayment for the esophagus biopsy. You say that you had no idea there was a
copayment for this procedure. 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 $200
copayment for surgery services at an in-network ambulatory surgical center.

You have been asked to pay a $200 copayment for the esophagus biopsy. The esophagus biopsy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The esophagus biopsy is considered a surgical procedure. 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 esophagus biopsy provided on August 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the biopsy you had on June 29, 2020, and
the ultrasound you had on July 20, 2020.

You asked the Plan to waive the copayments for the biopsy and the ultrasound. You say that you are disputing
these claims. The Plan denied your request. The Plan says you were charged these two copayments correctly.
The Plan says that it has reprocessed the claim for the July 6, 2020 date of service, so that date of service is not
part of this decision.

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 $270
copayment for outpatient surgery and a $20 copayment for ultrasounds.

You have been asked to pay a $270 copayment for the biopsy. The biopsy and the ultrasound falls within the
outpatient surgery benefit category. In addition, you have been asked to pay a $20 copayment for the
ultrasound you had. This means that you have been asked to pay the correct amounts 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 biopsy you had on June 29,
2020, and the ultrasound you had on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on April 26, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says this claim was billed with an inappropriate Place of Service code.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was submitted with the laboratory place of service code while the records show the specimen was obtained in the member's home. Therefore, we decided that the Plan does not have to pay for laboratory services provided on April 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a clinical nurse specialist on May 11, 2020.
You asked the Plan to waive the copayment for the specialty visit. You say that you saw a nurse practitioner, not a specialist. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for specialist visits. You have been asked to pay a $25 copayment for the specialty visit. Your Evidence of Coverage states that the specialist copayment applies to Practitioner/Professional services in addition to the services of a physician. That is why the visit you had falls within the specialist visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the visit you had with a clinical nurse specialist on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount for the limited oral evaluation (D0140),
the extraction (D7140), and the unspecified preventive service (D1999) provided on July 8, 2020.
You asked the Plan to reimburse the full amount for the dental services. You say that extractions are a covered
service. You say that you were given 5 different doctors who were participating providers but their numbers
did not work. You also say that no dentists accept your insurance. The Plan denied your request. The Plan says
the provider in this case is not a network provider. The Plan says that dental services that you receive out of
network 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.
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
reimburse the full amount for the limited oral evaluation (D0140), the extraction (D7140), and the unspecified
preventive service (D1999) provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), core build up (D2950 x 2), retainer crown (D6750 x 2), the pontic (D6240), and the unspecified preventive service (D1999) provided on August 5, 2020.
You asked the Plan to pay for the dental services. You say that your manual says that you have a certain percentage of coverage for dental services. You say that the services were denied despite the booklet stating a certain percentage will be paid. You also say that the services should be covered as stated in the manual that you received. The Plan denied your request. The Plan says the dental services that you received are not listed as covered 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 services you received are not among those covered under this benefit. The record shows that you changed plans, effective December 1, 2020. The booklet in your appeal is for your new plan, which was effective December 1, 2020. The services you received are not covered under the plan you had on this date of service. Therefore, we decided that the Plan does not have to pay for the extraction (D7210), core build up (D2950 x 2), retainer crown (D6750 x 2), the pontic (D6240), and the unspecified preventive service (D1999) provided on August 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the interlaminar epidural steroid injection
(62321) provided on August 3, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 in-network Medicare-covered surgery or other services provided at an ambulatory surgical
center or outpatient hospital, including but not limited to hospital or other facility charges and physician or
surgical charges.
You have been asked to pay a $250 copayment for the Medicare-covered service provided to you at an
outpatient hospital. You received services from an out-of-network hospital and would have been charged a
40% coinsurance but the Plan granted an exception and the claim was processed as in-network. 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 interlaminar epidural steroid injection (62321) provided on
August 3, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on February 25, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on February 25, 2020.
Appeal type: Practitioner Services
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 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate
claim.
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 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on April 23, 2020.
You asked the Plan to pay for drug testing. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the correct POS code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that Medicare must use the place of service (POS) codes from the National POS code set. POS 11 indicates an Office setting. POS 81 indicates an Independent Laboratory, which is a laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office. We find that the billing of this claim is not supported in the medical record. Specifically, this was billed with POS 81, but the record indicates the specimen tested was collected in an office setting. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on April 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram, routine ECG provided on August 3, 2020.
You asked the Plan to pay for the electrocardiogram, routine ECG. The Plan denied your request. The Plan says
that 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 an electrocardiogram, routine ECG provided on August 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the negative pressure wound therapy electrical pump coded
E2402 provided on May 18, 2020.
You asked the Plan to pay for the negative pressure wound therapy electrical pump. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was inpatient
for this date of service
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 E2402 is negative pressure wound therapy electrical
pump, stationary or portable.
We find that CPT code E2402 is not supported in the medical record. Specifically, the enrollee was in an
inpatient status for this date of service. The institution is expected to provide all medically necessary durable
medical equipment during an enrollee's covered stay. Therefore, this item is not separately payable. Based on
this information, we decided that Medicare rules for coverage of the negative pressure wound therapy electrical
pump have not been met. Therefore, we decided that the Plan does not have to pay for the negative pressure
wound therapy electrical pump coded E2402 provided on May 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from June 5, 2018, to June 7, 2018.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were told this claim would be written off by the hospital. The Plan denied your request. The Plan says the copayment 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 $325 copayment per days, days 1 to 5 with the day before you are discharged as your last inpatient day for inpatient hospital care. You have been asked to pay a total cost share of $650 (2 covered day x $325 copayment). The services provided 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 for the inpatient hospital care provided from June 5, 2018, to June 7, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network chiropractic services provided from July 23, 
2020, to August 14, 2020 that are not related to manual manipulation of the spine. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says only those service directly related to manual manipulation of the spine were 
paid. All other services provided and billed that do not relate to manual manipulation of the spine are not 
covered by Medicare when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for out of network 
chiropractic services provided from July 23, 2020, to August 14, 2020 that are not related to manual 
manipulation of the spine.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that at the current level of function, the enrollee does not require daily 
skilled therapy services on an inpatient basis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the outpatient observation stay provided 
from August 22, 2020, through August 23, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $350 
copayment per stay for outpatient observation stays.  
 
You have been asked to pay a $350 copayment for the outpatient observation stay 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 adjust the copayment for the outpatient observation stay provided from August 22, 2020, 
through August 23, 2020.