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

We decided that the Plan does not have to waive the copayment for the ambulance ride.

You asked the Plan to waive the copayment for the ambulance ride. You say that the ambulance was billed incorrectly because the hospital who called the ambulance said he was released home. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.

The enrollee has been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" 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 the ambulance ride.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electronic analysis of an implanted pump (62370) provided on January 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the electronic analysis of an implanted pump. You say that you would like reconsideration because the member is under your care for pain management. The Plan denied your request. The Plan says there is no authorization on file for the out-of-network 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 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 electronic analysis of an implanted pump (62370) provided on January 16, 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 cardiomyopathy panel rendered on May 7, 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 supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no submitted documentation to support that the testing was reasonable and medically necessary for the enrollee. 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 cardiomyopathy panel rendered on May 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) individual psychotherapy session, 60 minutes (90837) provide3d September 29, 2020 to December 23, 2020.
You asked the Plan to pay for the psychiatric services. You say that you live at least 30 miles or more from anyone covered under the plan. You thought this place was covered. You were 5 appointments in before you got the first denial. You are comfortable and happy and to continue seeing this provider. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) individual psychotherapy session, 60 minutes (90837) provide3d September 29, 2020 to December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection provided on October 6, 2020.
You asked the Plan to waive the copayment for the epidural injection. You say that you were never told you would have to pay $250. You say that you wouldn't have done the procedure if you knew the cost. The Plan denied your request. The Plan says the copayment 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 $250 copayment for Medicare-covered surgery at an outpatient hospital facility. You have been asked to pay a $250 copayment for the epidural injection. The epidural injection 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 epidural injection provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tissue transfer (14041, 14061) provided on August 31, 2020.
You asked the Plan to pay for tissue transfer. You say that these codes are supported. The Plan denied your request. The Plan says these codes are not documented.
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 14041 is adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm. The definition of 14061 is adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm. We find that CPT code 14041 and 14061 is not supported in the medical record. Specifically, the submitted medical records do not include clear documentation of tissue transfer being performed. Based on this information, we decided that Medicare rules for coverage of tissue transfer have not been met. Therefore, we decided that the Plan does not have to pay for tissue transfer (14041, 14061) provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 2) provided on September 8, 2020.
You asked the Plan to pay for the dental services. You say that this is your first time in 70 years having dental coverage. You say that you were advised the services were approved and that you would owe $162. You say that you received a bill for over $500. You say that you made the decision to get these services based on what you were quoted initially. You also say that you feel you should not be responsible for this bill. The Plan denied your request. The Plan says there is a maximum of $750 per year for dental services. The Plan also says that the 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, maximum benefit of $750 has been exhausted. The record shows that at the time the estimate was processed, you had $670 of the dental benefit remaining. After the estimate had processed for these services, other claims were submitted and paid.
Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4341 x 2) provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2020, by an
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 referring provider 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 August 11, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from September 18, 2020, to September 26, 2020.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you should only be responsible for a $450 copayment for gallbladder surgery on September 13, 2020. You say you do not believe the copayment should have started over. 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 a $150 copayment for each day for days 1-7 per admission and a $0 copayment each day for days 8-90 per admission. You have been asked to pay a $150 copayment for each day the inpatient hospital stay. ($150 x 7 = $1,050). The inpatient hospital stay falls within the "Inpatient Hospital 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 reduce the copayment for the inpatient hospital stay provided from September 18, 2020, to September 26, 2020.
Your complaint about the hospital discharging you prematurely 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided by on
October 20, 2020.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.
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 did not pre-approve the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on October 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for an outpatient surgery provided by a participating provider.

You asked the Plan to waive the coinsurance for an injection and copayment for an outpatient surgery. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance and copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs/in-network and a $250 copayment for outpatient surgery/in-network/outpatient hospital.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $250 copayment for an outpatient surgery. The amount you are being asked to pay for an injection is $1.43 ($7.17 x 20% = $1,43). The amount you are being asked to pay for outpatient surgeries is $500 ($250 x 2 surgeries = $500). The total amount you are being asked to pay is $501.43 ($1.43 + $500 = $501.43). An injection falls within the Medicare Part B prescription drugs/in-network benefit category and outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital 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 an injection and copayment for an outpatient surgery provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of Extracranial arteries.

You asked the Plan to pay for the duplex scan of Extracranial arteries. The Plan denied your request. The Plan
says non-emergent, non-urgent services with out-of-network providers require 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 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 duplex scan of Extracranial arteries.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 24, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 29, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was a free annual hearing test. You say that you should be reimbursed the $40 copayment. The Plan denied your request. The Plan says the copayment 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 $40 copayment for each covered specialist office visit.
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the office visit was for a follow up due to sensorineural hearing loss. 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 office visit provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (96366, 96365) provided on October 2, 2019.
You asked the Plan to pay for infusion services. You say that these services were approved by the Plan. The Plan denied your request. The Plan says these services must be billed first to the enrollee's primary insurance.
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 you to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for infusion services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for infusion services (96366, 96365) provided on October 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and allergy tests.

You asked the Plan to waive the copayment for the office visit and allergy tests. You say that you were charged more than your cardiologist, urologist and neurologist combined. The Plan denied your request. The Plan says the copayments 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 $25 copayment for each Medicare-covered specialist visit and a $150 copayment for other outpatient diagnostic tests (includes genetic testing).

You have been asked to pay a $25 copayment for the office visit and a $150 copayment for the allergy tests. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" and the allergy tests 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 the office visit and allergy tests.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intravascular ultrasound (37252 and 37253).
You asked the Plan to pre-approve the intravascular ultrasound. You say that you would like reconsideration
because the requested services are medically necessary. The Plan denied your request. The Plan says this
service is only medically necessary for assessing coronary arteries and renal arteries and veins.
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 intravascular ultrasound. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found there is insufficient evidence that use of intravascular ultrasound for lower
extremity arteries would result in appreciable better outcomes than standard treatment. There is no evidence
that the member's treatment would not be able to proceed without the availability of intravascular ultrasound.
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 intravascular ultrasound have not been met. Therefore, we decided that the
Plan does not have to pre-approve the intravascular ultrasound (37252 and 37253).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture.

You asked the Plan to pre-approve the mandibular partial denture. You say that you would like this service to be approved. The Plan denied your request. The Plan says this service exceeds the benefit allowance.

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 limited to 1 complete or partial denture every 5 years. The record shows that you received a mandibular partial denture and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiomyopathy risk factor screening (81286, 81404, 81407, 81408, 81479).

You asked the Plan to pay for cardiomyopathy risk factor screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of cardiomyopathy risk factor screening have not been met. Therefore, we decided that the Plan does not have to pay for cardiomyopathy risk factor screening (81286, 81404, 81407, 81408, 81479).