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

We decided that the Plan does not have to waive the copayments for ultrasounds provided on December 7,
2020, and December 8, 2020.
You asked the Plan to waive the copayments for ultrasounds. You say that you disagree with the increase in
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 $160
copayment for each radiological diagnostic service.
You received an ultrasound on December 7, 2020. Therefore, you are responsible to pay the $160 copayment.
You received an ultrasound on December 8, 2020. Therefore, you are responsible to pay the $160 copayment. The total amount you owe is: $320. You have been asked to pay the total copayment amount of $320 for ultrasounds. Ultrasounds 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 copayments for ultrasounds provided on December 7, 2020, and December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on February 9, 2021.
You asked the Plan to pay for the testing services. You say that the services were provided in good faith. The Plan denied your request. The Plan says there is no reason why 22 classes of drugs would need to be tested.
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 G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. The medical records provided do not indicate 22 or more specific drugs that needed to be tested based on suspicious behaviors or changes in behavioral patterns. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on February 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the infusion treatments provided from November 2, 2020, to December 9, 2020.
You asked the Plan to waive the cost share for the infusion treatments. You say that you were advised that the Plan covered these treatments. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance for each in-network Medicare-covered Part B drug and a $325 copayment for other services provided to you at an in-network outpatient hospital.
You have been asked to pay a total of $3,441.41 for the infusion treatments. The infusion treatments fall within the "Medicare Part B Prescription Drugs" and the "Outpatient Surgery and Other Medical 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 cost share for the infusion treatments provided from November 2, 2020, to December 9, 2020.
Your complaint about being treated indifferently and unfairly 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 computerized ophthalmic diagnostic imaging (92133) and the visual field examination (92083) rendered by the out of network (OON) provider on January 22, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the computerized ophthalmic diagnostic imaging (92133) and the visual field examination (92083) rendered by the out of network (OON) provider on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99232) observation or inpatient hospital care (99236) provided October 3, 2019 to October 7, 2019.

You asked the Plan to pay for the inpatient hospital services. You say that the insurance that you were given by the enrollee was incorrect. Upon receipt of the correct insurance information, you promptly submitted your claim to the claims department. The Plan denied your request. The Plan says this claim was submitted past the timely filing limitation.

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 inpatient hospital services was not filed until February 18, 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 subsequent hospital care (99232) observation or inpatient hospital care (99236) provided October 3, 2019 to October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 6, 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 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 pharmacogenetic 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 July 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on December 2, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you disagree with the charge. The Plan denied your request. The Plan says the copayment 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 a $90 copayment for each emergency room visit.
You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls within the Emergency 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 emergency room visit provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on January 12, 2021 by an OON provider.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that this provider is listed as in-network in the Plan's provider directory. You also say that you were advised that this provider was OON when you visited the office. The Plan denied your request. The Plan says the total liability amount of $165.00 was applied correctly. The Plan also says that the member liability is a contractual obligation under the Plan and cannot be waived.

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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on January 12, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulative treatments and office visits provided by a chiropractor from July 1, 2020, to December 11, 2020.
You asked the Plan to pay for chiropractic services. You say that this provider is in-network and you cannot get an answer to why these claims are being denied. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulative treatments and office visits provided by a chiropractor from July 1, 2020, to December 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET with CT (78815) provided on January 26, 2021.

You asked the Plan to pay for the PET with CT. You say that you would like reconsideration because the services were medically necessary and billed with the appropriate diagnosis code. The Plan denied your request. The Plan says this claim was not billed with the appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 78815 is not supported in the record. Specifically, the Medicare Claims Processing Manual includes a list of appropriate diagnosis codes for the service billed. The diagnosis code on the claim is not listed as an appropriate diagnosis code for PET with CT. Based on this information, we decided that Medicare rules for coverage of the PET with CT have not been met. Therefore, we decided that the Plan does not have to pay for PET with CT (78815) provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9502) provided on May 28, 2020 to July 8, 2020.

You asked the Plan to pay for home infusion therapy. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed with a valid code.

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 S9502 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 (S9502) provided on May 28, 2020 to July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture (D0380) and comprehensive oral evaluation (D0150) provided on February 10, 2021.

You asked the Plan to pay for the cone beam CT image capture and comprehensive oral evaluation. You say that you would like these services to be covered. The Plan denied your request. The Plan says the cone beam CT image capture is not covered under your plan. The Plan also says that the comprehensive oral evaluation does not meet the Plan's frequency requirements.

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 cone beam CT image capture (D0380) is not among those covered under this benefit. The contract says that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on January 13, 2021 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam CT image capture (D0380) and comprehensive oral evaluation (D0150) provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy.
You asked the Plan to pre-approve the Hyperbaric Oxygen Therapy. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says there is no documentation of surgical flap done recently.
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 Hyperbaric Oxygen Therapy. Our reviewer says that the requested items/services do not meet Medicare criteria for coverage. Our physician reviewer found upon review of the provided records, the member does not meet criteria for such therapy according to the NCD criteria as she has not had a recent surgery, did not have a progressive infection, diabetes, or other condition to warrant this request. 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 Hyperbaric Oxygen Therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMs device.

You asked the Plan to pre-approve a CardioMEMs device. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not met.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

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 a CardioMEMs device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure (CHF), which appear very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute CHF hospitalization or rapidly recurrent symptoms in this enrollee, use of the Cardiomems device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one and it would not be considered investigational. Continued effectiveness of the device in post marketing approval studies has been recently demonstrated as well. Cardiomems device implantation in this enrollee would therefore meet the medical reasonableness and necessity criteria of the applicable CMS Section 1862(a) 1(A) rule.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMs device have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMs device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mobile x-ray services rendered on December 3, 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure codes R0070 (transportation of portable x-ray equipment) and Q0092 (set-up portable x-ray equipment) have a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the mobile x-ray services rendered on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (CPT 97032) provided to the enrollee on November 4, 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 there is a more appropriate code to use in this case.
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 97032 is "manual electrical stimulation (e-stime) to one or more areas, each 15 minutes." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found there is a more appropriate code (HCPCS G0283) to report for the services that were performed on this date of service. We looked at this coder's review, the file, and Medicare rules. 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 therapy services (CPT 97032) provided to the enrollee on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and bitewing x-ray (D0274) provided on December 2, 2020.
You asked the Plan to pay for the dental services. You say that you contacted the plan prior to making an appointment. You say that you were assured the services would be covered. You say that you should not have to pay this bill as you were advised the services would be covered. You also say that this bill would be a financial hardship. The Plan denied your request. The Plan says there is an annual maximum benefit of $2,000 for covered dental services. The Plan also says that the annual maximum benefit 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 and the services are listed as covered, the annual maximum benefit has been exhausted.
The Evidence of Coverage clearly states after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and bitewing x-ray (D0274) provided on December 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, the panoramic x-ray, and the extraction provided on September 25, 2020.
You asked the Plan to pay for the dental services. You say that you had pain in your back bottom tooth. You say that your daughter got you in to see this dentist on a Friday. You say that you could not make it through the weekend due to the pain. You say that the office advised they did not accept your plan. You also say that this
was the first time you have ever been told this. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot be made for dental services performed by a provider that has opted out of Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by a provider that has opted out of Medicare are not among those covered under this benefit. Additionally, the record shows that you signed a form acknowledging that the provider had opted out of Medicare and any charges would be your responsibility. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, the panoramic x-ray, and the extraction provided on September 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2020 by an out of network (OON) provider.
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 were rendered by an out-of-network provider without 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 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 laboratory services provided on February 3, 2020 by an out of network (OON) provider.