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

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on December 9, 2020.
You asked the Plan to waive the copayment for these services. You say that you should not be charged a copayment. The Plan denied your request. The Plan says the copayment was 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 $20 copayment for lab services at a freestanding laboratory.
Review of the file shows that you received laboratory services on December 9, 2020. You have been asked to pay a $20 copayment for these services. These services fall within the lab services at a freestanding laboratory 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 laboratory services rendered on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for levonorgesterel-releasing intrauterine contraceptive system
(Mirena) and the insertion services provided on July 28, 2020.
You asked the Plan to pay for levonorgesterel-releasing intrauterine contraceptive system (Mirena) and the
insertion services. You say that you would like the plan to reconsider their denial. The Plan denied your
request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. The rules say that items/services for the purposes of preventing
conception (contraception) are not considered medically reasonable and necessary.
Records show that the requested service is primarily for the purpose of contraception. The documentation does
not show that this service is being requested to treat a specific illness/injury. As such, the Medicare rules for
coverage of this item/service have not been met. Therefore, we decided that the Plan does not have to pay for
levonorgesterel-releasing intrauterine contraceptive system (Mirena) and the insertion services provided on
July 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) received January 19, 2021.
You asked the Plan to pay for periodontal scaling and root planing. You say that you disagree with the plan's quarterly allowance. The Plan denied your request. The Plan says you have exhausted your $250 allowance for this quarter.
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 in excess of those covered under this benefit. The Plan has submitted evidence that your $250 quarterly allowance was exhausted. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) received January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 16, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 the laboratory services are not supported in the medical record. Specifically, these services should be billed with code 81479. In addition, the appropriate DEX Z code identifier should be entered adjacent in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the patient was admitted to an acute care hospital for hypotension and gastrointestinal
bleeding. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that this patient will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on November 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. 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 payable.
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 subsequent nursing facility care provided on November 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry services coded 88341 provided on July 16, 2020.
You asked the Plan to pay for the immunohistochemistry 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 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 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure). We find that CPT code 88341 is not supported in the medical record. Specifically, this code is an add-on code. This code was billed without an appropriate primary procedure code. This code cannot be separately reimbursed. Based on this information, we decided that Medicare rules for coverage of the immunohistochemistry services have not been met. Therefore, we decided that the Plan does not have to pay for the immunohistochemistry services coded 88341 provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on October 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 psychotherapy services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on November 11, 2020.

You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Guardant360 testing is only covered for certain indications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Guardant360 testing. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of Malignant neoplasm of overlapping sites of unspecified female breast. The rendered services are not medically necessary and not a standard of care for this enrollee. The Evidence-based guidelines do not support this type of testing for this condition. The review has determined that the documentation does not support that the enrollee has a diagnosis that meets criteria for the testing rendered. 

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 Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on November 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on January 9, 2020, January 21, 2020, and January 25, 2020 to January 26, 2020.
You asked the Plan to pay for the outpatient services. You say that you would like the plan to reconsider their decision. The Plan denied your request. The Plan says the services must be billed to the enrollee's primary insurance first.
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 directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the outpatient services until the primary insurer has denied the claim for these services. In addition, no additional payment may be made on a claim that has been processed and paid to the full Medicare allowed amount by the primary insurer. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on January 9, 2020, January 21, 2020, and January 25, 2020 to January 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 2, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 the laboratory services are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography (CT) chest (71250) provided September 24, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you never had to pay an additional fee. This new location has made a mistake and no balance is due. The Plan denied your request. The Plan says the claim was processed and the correct copay was 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 $110 copayment for each radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility. You have been asked to pay $110 copayment for the CT scan. The CT scan 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 computed tomography (CT) chest (71250) provided September 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs rendered on February 8, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you are being overcharged. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for Medicare Part B chemotherapy drugs, associated administration services, and all other Medicare Part B drugs.
Review of the file shows that you received chemotherapy drugs on February 8, 2021. You have been asked to pay a 20% coinsurance for these services, for a total of $178.76. These services fall within the Medicare Part B chemotherapy drugs, associated administration services, and all other Medicare Part B 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 the chemotherapy drugs rendered on February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiology mRNA testing provided on November 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the cardiology mRNA testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 cardiology mRNA testing provided on November 5, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) for teeth 25-32, local anesthesia (D9215) and oral hygiene instructions (D1330) provided on December 2, 2020.

You asked the Plan to pay for the dental services. You say that you cannot afford these services and you believed the cost would be lower. You can only afford the copayment that was originally quoted to you. You do not recall having these services at the previous dental office in 2019 but cannot get records to show this as the practice has closed. The Plan denied your request. The Plan says periodontal scaling and root planing for teeth 25-32 was previously provided for you in August 2019. The Plan can only cover this service once per quadrant every two years. Therefore, the benefit's maximum frequency was already met at the time of service and payment cannot be made. In addition, local anesthesia and oral hygiene instructions are not covered in any circumstances under the Plan's dental benefit.

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 or were provided in a frequency that exceeds what is covered by the Plan. Documentation shows that the Plan was billed and paid for periodontal scaling and root planing of this quadrant (teeth 25-32) in 2019. The local anesthesia and oral hygiene instructions are not listed as covered benefits by the Plan. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) for teeth 25-32, local anesthesia (D9215) and oral hygiene instructions (D1330) provided on December 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy services and outpatient surgery rendered on October 8, 2020 to October 16, 2020.
You asked the Plan to waive the copayments for these services. You say that you should not owe a copayment. The Plan denied your request. The Plan says the copayments were 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 $35 copayment for each in-network Medicare-covered therapy visit and a $325 copayment for an in-network surgical service at an outpatient hospital facility.
Review of the file shows that you received outpatient surgical services on October 8, 2020. You have been asked to pay a $325 copayment for these services. These services fall within the in-network surgical service at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received physical therapy services on October 16, 2020. You have been asked to pay a $35 copayment for these services. These services fall within the in-network Medicare-covered therapy visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $360. 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 physical therapy services and outpatient surgery rendered on October 8, 2020 to October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injection and infusion services (96372) pegfilgrastim-cbqv, biosimilar (udenyca) injection (Q5111) provided November 12, 2020.
You asked the Plan to waive the copayment for the injection services. You say that you are receiving a bill from the hospital for an injection. No other injection was so costly and is unsustainable for their household. The Plan denied your request. The Plan says this claim was processed and 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 20% coinsurance for all other Medicare Part B covered drugs. You have been asked to pay $733.95 for the injection services. The injection services 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 copayment for injection and infusion services (96372) pegfilgrastim-cbqv, biosimilar (udenyca) injection (Q5111) provided November 12, 2020.