Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on January 29, 2020.
You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You say that you located this provider in the Plan's 2020 provider directory. You also say that you called the group and was told they were covered by your insurance plan. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on January 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery (66984) provided on
February 12, 2020.
You asked the Plan to waive the copayment for cataract surgery. You say that you have been billed twice for
this service. The Plan denied your request. The Plan says this service processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for surgery services provided in an ambulatory surgical center.
You have been asked to pay a $50 copayment for cataract surgery, a surgery service provided in an ambulatory
surgical center. 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 cataract surgery (66984) provided on
February 12, 2020.
Your complaint about how the facility is billing you 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 and the
hospital discharge day management services coded 99238 provided on July 30, 2019 and July 31, 2019.
You asked the Plan to pay for the subsequent hospital care services and the hospital discharge day management
service. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan
says the services billed are included in the payment of other services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes
99232 and 99238 for the subsequent hospital care services and the hospital discharge day management service
have a bundled relationship with other evaluation and management services that were billed and reimbursed
under claim 820192261050668 and cannot be paid as billed. This code cannot be paid as a separate line item.
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan
does not have to pay for the subsequent hospital care services coded 99232 and the hospital discharge day
management services coded 99238 provided on July 30, 2019 and July 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the transportation services provided on October
28, 2019.
You asked the Plan to reimburse you for the wheelchair van transportation services. You say that you had to
take the wheelchair van home so you could get in-network therapy. The Plan denied your request. The Plan
says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport
services.
The services you have asked the Plan to reimburse you for are wheelchair van transport services. Therefore, we
decided that the Plan does not have to reimburse you for the transportation services provided on October 28,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from December 15, 2019 to
December 21, 2019.
You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the hospital
did not request authorization from the Plan.
The Plan must follow Medicare rules. The rules say that plans do not have to pay for non-plan care except for
emergencies, out-of-area urgently needed care, post-stabilization care, and pre-approved care.
We looked at the file and the Medicare rules. Medicare says that when post-stabilization care is obtained from a
non-contract provider, approval is required from the Plan. The file shows that the hospital did not seek preapproval
from the Plan prior to providing post-stabilization care services. The Plan did not pre-approve the inpatient
admission. 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 inpatient admission provided from
December 15, 2019 to December 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 10, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claims were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an
independent laboratory; however, the file shows that the specimen was obtained in an office setting and should
have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug
testing rendered on December 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 3,
2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that the copayment is excessive for a
procedure that has to be done. 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 $395
copayment per in-network visit.
You have been asked to pay a $395 copayment for the colonoscopy. The colonoscopy 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 copayment for the colonoscopy provided
on February 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (CPT 99350) provided to the enrollee
on September 4, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says a home visit cannot be billed by a physician unless the physician (or advanced practitioner) was
actually present in the home.
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 99350 is "Home visit for the evaluation and management
of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval
history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a
significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face
with the patient and/or family."
We find that CPT code 99350 is not supported in the medical record. Specifically, the medical records show
that the visit was signed off on by an LVN. This code requires a physician presence, not a LVN. Based on this
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we
decided that the Plan does not have to pay for home health services (CPT 99350) provided to the enrollee on
September 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from
December 22, 2019 to December 23, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be
charged a copayment because you were admitted to the hospital. 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 $50
copayment for emergency services in an in-network emergency room.
You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. The record shows that you are only liable for the ER copayment
for this claim and that you were admitted to outpatient observation.
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 emergency room visit provided from December 22, 2019
to December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 30, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that
the member's primary care physician did not refer these 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 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 lab work provided on October 30, 2019 by an out
of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve, and the lumbarsacral
orthosis provided on November 8, 2019.
You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397), and the lumbar-sacral
orthosis (L0650). You say that the Plan should pay this claim. The Plan denied your request. The Plan says
rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and
suspension sleeve, and the lumbar-sacral orthosis provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on
October 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care 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.
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 for the subsequent nursing facility care services
provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you would like to appeal the Plan's
denial of the requested incontinence supplies. You say that the requested items should be covered for you by
the Plan. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 15, 2020.
You asked the Plan to pay for drug test. You say that you are appealing with supporting documentation. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because the
documentation submitted does not include a valid physician order, lab requisition, or medical records stating
exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code G0481 is not supported.
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 G0481 is definitive drug testing, 8-14 drug classes.
We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation
of testing of 8-14 drug classes. Based on this information, we decided that Medicare rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on July 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 18, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on October 2, 2019.
You asked the Plan to waive the copayment for an eye exam. You say that you did not receive a medical exam and 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for exams to diagnose and treat diseases or conditions of the eye. The medical records show that you had an eye exam on October 2, 2019. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for an eye exam. An eye exam falls within the vision 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 an eye exam provided on October 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from May 8, 2019 to August 13, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you are dissatisfied with having the pay $80 for the physical therapy visits. 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 $20 copayment for outpatient rehabilitation services. You have been asked to pay a $20 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The medical record shows you received physical therapy on these dates of service.
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 physical therapy visits provided from May 8, 2019 to August 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on November 4, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency care. The enrollee has been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ER visit provided on November 4, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90847) provided on
January 3, 2020 through January 6, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that you would like
reconsideration because this provider is contracted with Medicare. The Plan denied your request. The Plan says
this type of provider is not allowed per Medicare.
The Plan must follow Medicare rules. Medicare rules say that Licensed Professional Counselors and Marriage
Family Therapists are not eligible to enroll in Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient mental health services have not been met. Specifically, this provider's primary
taxonomy indicates that they are a Marriage Family Therapist. Marriage Family Therapists are not eligible to
enroll in Medicare. Therefore, we decided that the Plan does not have to pay for outpatient mental health
services (90847) provided on January 3, 2020 through January 6, 2020.