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

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from April 8, 2020, to May 26, 2020.
You asked the Plan to pay for home infusion therapy. You say that this was billed correctly with a correct tax identification. The Plan denied your request. The Plan says this was not billed with a valid tax identification.
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 S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from April 8, 2020, to May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood count services coded 85025 provided on July 13, 2020.
You asked the Plan to pay for the blood count services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 85025 is Blood count; complete (CBC), automated (Hgb,
Hct, RBC, WBC and platelet count) and automated differential WBC count.
We find that CPT code 85025 is not supported in the medical record. Specifically, these services were a
different provider than the facility for services furnished to the enrollee for surgery. The facility must furnish
all necessary covered services to the beneficiary either directly or under arrangements made between the
facility and outside vendors. The enrollee received the services in preparation for surgery at the facility.
Payment for this service would be included in the facility PPS payment. Based on this information, we decided
that Medicare rules for coverage of the blood count services have not been met. Therefore, we decided that the
Plan does not have to pay for the blood count services coded 85025 provided on July 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you received on January 9, 2020.
You asked the Plan to waive the copayment. You say that you were told there would be no copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 each Medicare-covered radiological diagnostic service. Review of the file shows that you were provided an ultrasound on January 9, 2020. Per your contract the Plan, there is a $125 copayment for outpatient radiological diagnostic services. However, the Medicare allowed amount for these services was $108.21. Given that the allowed amount was less than the $125 copayment, you have been asked to pay $108.21 for these services. 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 ultrasound you received on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forimmunotherapy service provided on April 21, 2020.You asked the Plan to waive the copayment forspecialist visit. You say that this cost-share was not in the Evidence of Coverage or Annual Notice of Change for 2020.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $35 copayment for specialist visit. You have been asked to pay the allowed amount of $10.36, which is less than the $35 copayment for specialist visit. Specialist 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 forimmunotherapy service provided on April 21, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray (73523) provided on October 1, 2020 by an out of network (OON) provider.You asked the Plan to pay foran OON x-ray. You say that this is supported by the records.The Plan denied your request. The Plan says this was not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 forthe x-ray (73523) provided on October 1, 2020 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 podiatry services provided by a participating provider on October 13, 2020.

You asked the Plan to waive the copayment for podiatry services. You say that you do not agree with this. You say that you have never had a copayment for this before. 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 $15 copayment for physician/practitioner services/specialist. 

You have been asked to pay a $15 copayment for podiatry services. The correct copayment has been applied to the services that were provided. Podiatry 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 podiatry services provided by a participating provider on October 13, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray coded 71046 provided on September 2, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 71046 is radiologic examination, chest; 2 views.
We find that CPT code 71046 is not supported in the medical record. Specifically, the claim was billed with
place of service 22 (outpatient). According to the documentation, the enrollee was inpatient for this date of
service. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not
been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray coded 71046 provided
on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper partial denture provided on March 15, 2019.
You asked the Plan to pay for the upper partial denture. You say that at the time of treatment you didn't realize
the Plan would be liable for the cost. You say that the denial should be reconsidered. The Plan denied your
request. The Plan says the claim was filed outside of the twelve-month timeframe.
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 claim for the upper partial denture was not filed until August 4, 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 for the upper partial denture provided on March 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the remaining amount forthe 2 resin based composites provided on November 4, 2020.You asked the Plan to pay the remaining amount forthe dental services. You say that you do not know to what extent the services you received were covered. You say that you are being penalized for your dental visit in August. You also say that this is an unexpected charge to you.The Plan denied your request. The Plan says there is a $200 allowance for fillings and simple tooth extractions every year. The Plan says that the allowance has been exhausted.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 $200 allowance for fillings and simple extractions has been exhausted. The record shows that the Plan paid $150 towards the services you received on August 6, 2020. The record also shows that the Plan paid $50 towards the fillings that you received on the date of service in this case, thus exhausting the $200 allowance.Therefore, we decided that the Plan does not have to pay more for the 2 resin based composites provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for 4 office visits (99213) provided August 19, 2020 to September 23, 2020.
You asked the Plan to waive the copayments for the office visits. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 $45 copayment for Specialist Visits. You have been asked to pay four $45 copayments for the office visits. The office visits fall 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 copayments for 4 office visits (99213) provided August 19, 2020 to September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and laboratory services provided on January
17, 2020 by an out of network provider.
You asked the Plan to pay for the office visit and laboratory services. You say that the Plan should pay this
claim. The Plan denied your request. The Plan says you did not request 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 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 laboratory services provided on January 17, 2020 by
an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained.
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 physician services provided on April 23, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on February
20, 2020.
You asked the Plan to waive the copayment for the breast ultrasound. You say that your primary care physician
gave a prescription for the mammogram, but the facility also requested an ultrasound. The Plan denied your
request. The Plan says the claim was processed accordingly with your 2020 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).
Review of the file show that you received the breast ultrasound on February 20, 2020. The Medicare-allowed
amount for the radiological diagnostic service is less than the set $155 copayment; therefore, you have been
asked to pay the lesser amount of $136.76 for the ultrasound. 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 breast ultrasound provided on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve push handles for a wheelchair.
You asked the Plan to pre-approve the handles. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve push handles for a wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the echocardiogram and the vascular
ultrasound provided on July 8, 2020.
You asked the Plan to reduce the copayments for the echocardiogram and vascular ultrasound. You say that
you received a bill for two non-radiological tests and that the services were pre-approved. You say you should
be paying a $30 copayment. The Plan denied your request. The Plan says you have been charged the correct
cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed at an innetwork physician's office or at a free-standing facility (such as radiology center or medical clinic).
You have been asked to pay a $160 copayment for the echocardiogram and a $160 copayment for the vascular
ultrasound. ($160 + $160 = $320). The echocardiogram and vascular ultrasound falls within the "Outpatient
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the
echocardiogram and the vascular ultrasounds are considered radiological procedures.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to reduce the copayments for the echocardiogram and the vascular ultrasound provided
on July 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the arthrocentesis with ultrasound
guidance provided on September 17, 2020.
You asked the Plan to reduce the copayment for the arthrocentesis with ultrasound guidance. You say that the
member has received injections in the past which did not have the ultrasound guidance or the $350 copayment.
You say this should only be a $45 copayment. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment per day for outpatient procedures and services, including but not limited to diagnostic and
therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical
center.
You have been asked to pay a $350 copayment for the arthrocentesis with ultrasound guidance. The
arthrocentesis with ultrasound guidance falls within the "Outpatient surgery, including services provided at
hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the
arthrocentesis with ultrasound guidance 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 reduce the copayment for the arthrocentesis with ultrasound guidance provided on
September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two SI joint RFA.
You asked the Plan to pre-approve the RFA. You say that you would like reconsideration because the member
received 80% pain relief from both SI blocks. The Plan denied your request. The Plan says this treatment is not
covered by Medicare.
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 RFA. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found SI joint ablation is experimental. More research is needed to show safety and efficacy. The use
of radiofrequency ablation for pain management related to sacroiliitis has not been shown to provide clear
long-term benefit than standard treatment for chronic sacroiliac joint pain.
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 RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve two SI joint RFA.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete lower denture (D5120).You asked the Plan to pre-approvethe dental item. You say that your previous denture was made by the "only" plan dentist availableto you. You say that the dentist's hands shook regularly. You say that you were supposed to have soft liners, but were given hard liners. You say that the lower denture has not worked since it was made. You also say thatThe Plan denied your request. The Plan says dentures are covered once every 5 plan years. The Plan says that the frequency limit for this item has been reached.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 frequency limit of 1 denture every 5 plan years has been reached. The record shows that the Plan approved and paid for a complete lower denture that you received on September 28, 2018.Therefore, we decided that the Plan does not have to pre-approvea complete lower denture (D5120).Your complaint about your dissatisfaction with the previous dentistis 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
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical assistant services on a laparoscopy (47562) provided on July 23, 2020.You asked the Plan to pay forsurgical assistant services. You say that this should be covered.The Plan denied your request. The Plan says this service is not covered when provided by an RNFA.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forsurgical assistant services on a laparoscopy (47562) provided on July 23, 2020.