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

We decided that the Plan does not have to pay for chiropractic services provided on November 26, 2019, December 10, 2019 and December 12, 2019.You asked the Plan to pay for the chiropractic services.The Plan denied your request. The Plan says 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 emergency situation, 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 incases 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 servicesat 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 chiropractic services provided on November 26, 2019, December 10, 2019 and December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory tests provided on March 2, 2020.
You asked the Plan to waive the copayment for the laboratory tests. You say that the provider informed you that the blood test had to be done again. You say that the provider should cover 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 $30 per day, per in-network provider, for Medicare-covered lab services. You have been asked to pay $13.30, which is less than the standard $30 copayment for the laboratory tests. The laboratory 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 laboratory tests provided on March 2, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a CT Scan of the head or brain (70450) provided on January 10, 2020.
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says that services that are considered column II procedures
to another service are not eligible for reimbursement when billed with the column I procedure code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 70450 is supported in the record. Specifically, CPT code 70450 was provided by a
provider with a separate NPI than the column I procedure. Based on this information, we decided that Medicare
rules for coverage of the CT Scan have been met. Therefore, we decided that the Plan has to pay for a CT Scan
of the head or brain (70450) provided on January 10, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 10, 2020 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 services were rendered by a non-participating 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 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 January 10, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the core buildup. You say that the tooth has recurrent caries and this tooth can be saved. You also say that if you restore the tooth, you expect longevity of more than 5 years for the tooth. The Plan denied your request. The Plan says this service is not covered by 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided form May 4, 2019 to May 7, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you are not sure the enrollee had a semi-private room and could not give the enrollee medication. 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 $275 copayment per day for days 1-7 for inpatient hospital care. The enrollee had an inpatient hospital stay from May 4, 2019 to May 7, 2019. Therefore, the enrollee is responsible to pay a $275 copayment for days 1-3 (May 4, 2019 to May 6, 2019). $275 (copayment) x 3 (inpatient days) = $825. The enrollee has been asked to pay the total copayment amount of $825 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 inpatient hospital stay provided form May 4, 2019 to May 7, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for an ophthalmological exam. We decided that the Plan does not have to pay for refraction. You asked the Plan to waive the coinsurance for an ophthalmological exam. You say that these services should be covered.The Plan says that these services processed correctly.We decided that the Plan has to pay for an ophthalmological exam. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay $0 for Medicare-covered vision care.The Plan says you must a 20% coinsurance for an ophthalmology exam. Based on the Plan contract, however, you cannot be asked to pay more than $0 for an ophthalmology exam. Therefore, we decided that the Plan has to waive the coinsurance for an ophthalmological exam. We also decided that the Plan does not have to pay for refraction.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The refraction you asked the Plan to pay for are considered a routine vision service.Therefore, we decided that the Plan does not have to pay for refraction.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a second of unit of a cervical MRI provided to the enrollee on March 23, 2019.
You asked the Plan to pay for the additional MRI. You say that the claim denied as duplicate in error. The Plan denied your request. The Plan says there is no additional documentation supporting an additional study was provided.
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 72141 is "Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the additional MRI. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the provided records has been paid for the MRI of the cervical spine dated 3/23/19 via check dated 12/21/19 in the amount of $277.00. There is no record in the chart to provide indication for another payment for MRI services. 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 additional MRI have not been met. Therefore, we decided that the Plan does not have to pay for a second of unit of a cervical MRI provided to the enrollee on March 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you do not see the patient. You say that you would like this appeal reprocessed and approved. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that no prior authorization was obtained.
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 December 6, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the
$1,296.05 charge. 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 20%
coinsurance for Medicare Part B prescription drugs.
You received Medicare Part B drugs. The total allowed amount is $6,480.28 and 20%
of that is $1,296.05.
You have been asked to pay the total coinsurance amount of $1,296.05 for Medicare Part B drugs. Medicare
Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for Medicare Part B drugs.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy (S9328) provided from November 20, 2019, to November 27, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is an invalid code.The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Procedure code S9328is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided thatMedicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy (S9328) provided from November 20, 2019, to November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Diclofenac Sodium 1% Gel.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee has a medical (MA) only policy with the Plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Diclofenac Sodium 1% Gel.
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided.
You asked the Plan to pay for the services provided. You say that the code is valid and billable. The Plan denied your request. The Plan says the billed services cannot be verified.
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 81479 is unlisted molecular pathology procedure. We find that the services are not supported in the medical record. The records provided do not include a description of the services billed. There are insufficient records to show that the services were billed with most comprehensive codes. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the testing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the
provider is not in-network and there is no authorization on file.
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 physician's services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on January 31, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you 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 services obtained by a specialist. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 foraspecialist visit provided on January 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 3, 2020.You asked the Plan to waive the copayment for the ambulance transport. You say that you didn't need anything other than an SUV or wheelchair accessible vehicle. You say that you should have a $0 copayment for a non-emergency ride.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 ambulance services. Cost sharing applies for each one-way trip.You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided.
You asked the Plan to waive the copayment for wound debridement. You say that the provider made the appointment with the wound clinic. You say that you shouldn't have to pay for this. 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 $35 copayment for each in-network specialist visit for Medicare-covered services. Covered services include medically-necessary care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. You have been asked to pay a $35 copayment for wound debridement. Wound debridement falls within the "Physician/Practitioner services, including doctor's office visits" 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 wound debridement provided
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were not provided with any rationale for the denial of the prophylaxis and periodic oral evaluation. You also say that your appeal is based on the coverage as stated in the Plan's benefits booklet. The Plan denied your request. The Plan says this provider has opted out of Medicare. The Plan also says that payment cannot be made to providers that opt out of Medicare.
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. This provider has opted out of the Medicare program. The file shows that the treating provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injections provided on December 11, 2019 and March 10, 2020.
You asked the Plan to waive the coinsurance for the Botox injections. You say that you were treated by the doctor for migraines. You say that your primary doctor can't give the medical treatment. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total of $499.20 for the Botox injections.

The Botox injections fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Botox injections provided on December 11, 2019 and March 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental implant (D6010) provided January 7, 2020 and January 9, 2020.You asked the Plan to pay forthe dental services. You say that you are appealing the denial of the denied services.The Plan denied your request. The Plan says this service is not covered under the plan 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. The health plan contract says that services not listed is not covered.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 forthe dental implant (D6010) provided January 7, 2020 and January 9, 2020.