Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on February 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you expect that this claim is reviewed and processed considering the attached documents and considering the circumstances under which the services were rendered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 chiropractic manipulative treatment (98941) provided on February 6, 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 the four interim caries arresting medicament applications (D1354 x4) provided on March 4, 2021.
You asked the Plan to pay for the interim caries arresting medicament applications. You say that these services were unplanned treatment that you would like covered by your insurance. The Plan denied your request. The Plan says this service is not a covered 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. Therefore, we decided that the Plan does not have to pay for the four interim caries arresting medicament applications (D1354 x4) provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy (D3421), two retrograde fillings (D3430 x2), and incisional biopsy of oral tissue-soft (D7286) provided on February 11, 2021.
You asked the Plan to pay for the apicoectomy, retrograde fillings, and incisional biopsy. You say that you would like to make sure these services are non-covered, and that the provider used the correct codes. The Plan denied your request. The Plan says these services 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, 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 apicoectomy (D3421), two retrograde fillings (D3430 x2), and incisional biopsy of oral tissue-soft (D7286) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on March 12, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that you went to this eye exam visit with
the intention for a glaucoma screening. The Plan denied your request. The Plan says that the Plan contacted the
physician's office, and it was confirmed that you were previously diagnosed with glaucoma, and this exam was
a follow-up for glaucoma treatment.
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 $40
copayment for vision care, Medicare-covered eye exams.
You have been asked to pay a $40 copayment for the eye exam. The eye exam falls within the vision care,
Medicare-covered eye exams 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 March 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2021.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 services was not filed until March 3, 2021. 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 services provided on December 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81225, 81226, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81408) provided June 30, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service cannot be paid as billed. A single code must be billed for a panel.
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS code must be submitted for the panel. We looked at the file and Medicare rules. The service at issue is a genetic testing panel. The service was unbundled. Only one code can be paid for a testing panel. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (81225, 81226, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81408) provided June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021.
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 services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, a COVID-19 test, was requested solely for screening purposes. Medicare does
not cover this test solely for screening purposes. The file shows that the testing was performed for the purposes
of travel. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on
January 26, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on January 22, 2021.
You asked the Plan to waive the copayment for these services. You say that you should not have to pay. 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 $45 copayment for specialist physician services.
Review of the file shows that you received specialist services on January 22, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the specialist physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Nucala infusions you received in an outpatient hospital setting from January 28, 2021, to February 26, 2021.
You asked the Plan to waive the coinsurance for the Nucala infusions. You say that you were advised by the Plan that there would be no copayment for this service. In addition, you say that you were directed to have these services done at an outpatient hospital facility. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that you were sent an Annual Notice of Change that explicitly advised that starting in 2021, there would be 20% coinsurance for drugs received at an outpatient hospital facility.
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 Part B drugs you receive in an outpatient hospital setting.
You have been asked to pay 20% coinsurance for the Nucala infusions. You had these services at an outpatient hospital facility. 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 Nucala infusions you received in an outpatient hospital setting from January 28, 2021, to February 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient hospital visit (G0463), an x-ray of the knee (73564), a diagnostic imaging procedure (76499) and physical therapy (97110) provided on February 8, 2021, by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an outpatient hospital visit (G0463), an x-ray of the knee (73564), a diagnostic imaging procedure (76499) and physical therapy (97110) provided on February 8, 2021, by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81226, 81479, 81230) provided July 27, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the unbundled services cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis Current Procedural Terminology code.
We looked at the file and Medicare rules. Multiple codes were billed for a single genetic panel. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81225, 81226, 81479, 81230) provided July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 14, 2020.
You asked the Plan to pay for lab tests. You say that this claim has not been paid in full. The Plan denied your request. The Plan says the denial of payment for these services is correct, because predictive screening testing is not a Medicare benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Bortezomib injections (J9041) provided from January 5, 2021, through February 23, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $1,497.58 (Plan allowed amount of $1,069.73 x 20% coinsurance= $213.94 x 7) for the Medicare Part B drug injections 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 waive the coinsurance for the Bortezomib injections (J9041) provided from January 5, 2021, through February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee arthroplasty (27447-RT) provided on February 5, 2021.
You asked the Plan to pay for a right knee arthroplasty. You say that this service was requested with the in-network surgeon. The Plan denied your request. The Plan says this service was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Some International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral.
In this case, the RT modifier was used to indicate that the knee arthroplasty was performed on the right side. However, the billed diagnosis code, M17.12, indicates unilateral primary osteoarthritis of the left knee. The laterality of the procedure and the diagnosis do not match. Based on this information, we decided that Medicare rules for coverage of a right knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for a right knee arthroplasty (27447-RT) provided on February 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral (77065) diagnostic digital breast tomosynthesis (G0279) provided November 17, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that for over 20 years you have never paid for a mammogram or anything related to it. It has always been covered by Medicare. The Plan denied your request. The Plan says the claim was processed as a diagnostic procedure and the correct copayment 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 $10 copayment for x-rays and diagnostic procedures and tests.
You have been asked to pay $10 copayment for the diagnostic services. The diagnostic services fall 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 diagnostic mammography, including computer-aided detection (CAD) when
performed; unilateral (77065) diagnostic digital breast tomosynthesis (G0279) provided November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 14, 2020.
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 the place of service on the CMS-1500form line 24B must reflect the location of the patient when the specimen was obtained.
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 denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 laboratory services provided to the enrollee on July 14, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for COVID-19
provided on January 25, 2021.

You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be
reprocessed. The Plan denied your request. The Plan says Original Medicare would be responsible for payment
of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on January 24, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for COVID-19 provided on January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a push wheelchair.
You asked the Plan to pre-approve a push wheelchair. You say that the item is necessary. The Plan denied your request. The Plan says the enrollee is residing in long term care at a skilled nursing facility. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that if an individual is a patient in an institution or
distinct part of an institution which provides the services described in the bullets above, the individual is not
entitled to have separate Part B payment made for rental or purchase of DME.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a push wheelchair have not been met. Therefore, we decided that the Plan does not have to preapprove
a push wheelchair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cardiac surgery services provided on January 29, 2021.
You asked the Plan to waive the coinsurance for cardiac surgery services. You say that you had the same procedure in 2018 with no copayment under the same Plan and benefit. The Plan denied your request. The Plan says the correct copayment 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 20% coinsurance for each visit for outpatient surgery. You have been asked to pay $2,155.83, or 20% of the Medicare-allowed charge of $10,779.14, for cardiac surgery services. Cardiac surgery services fall 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 coinsurance for cardiac surgery services provided on January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services received from October 2, 2019, to March 26,
2020.
You asked the Plan to pay for the services. You say that you shouldn't have to pay anything on these claims.
The Plan denied your request. The Plan says the claim was not filed timely.
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 services was not filed until April 1, 2021. 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 services received from October 2, 2019, to March 26, 2020.