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

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) Colonography (74261) performed.
You asked the Plan to waive the copayment for the Colonography. You say that the procedure was not performed correctly and the copayment should be waived. 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 a $250 copayment for Outpatient Diagnostic Tests. You have been asked to pay a $237.11 copayment for the Colonography. The Colonography falls within the Outpatient Diagnostic Tests benefit category. The $237.11 is the Medicare allowable copayment for this service. This is less than the $250 stipulated in the plan contract. 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 a Computed Tomography (CT) Colonography (74261) performed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of residual tooth roots of the upper right quadrant provided on August 26, 2019.You asked the Plan to pay for the removal of residual tooth roots. You say that you had a fall and lost your teeth. You also say that you are requesting that this service be covered because of your accident.The Plan denied your request. The Plan says the benefit maximum for this period or occurrence has been reached.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 annual maximum benefit had been reached. The removal of residual tooth roots is a covered benefit; however, your plan contract clearly states that the covered comprehensive dental services may not exceed $900 every year. The record shows that your $900 benefit amount has been exhausted.Therefore, we decided that the Plan does not have to pay for the removal of residual tooth roots of the upper right quadrant provided on August 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided by the Ambulance Provider on July 30, 2019, August 5, 2019, August 13, 2019, and August 19, 2019.
You asked the Plan to pay for the ambulance transports. You say that you are bedridden and need to get to your specialists. The Plan denied your request. The Plan says a physician's office is not a covered destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for ambulance services provided by the Ambulance Provider on July 30, 2019, August 5, 2019, August 13, 2019, and August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you $150 for eyeglasses provided on April 2, 2019.You asked the Plan to reimburse you $150 for the eyeglasses. You say that since you are paying for vision insurance with the Plan, you are eligible to receive reimbursement when you purchase eyeglasses. You say that you were able to purchase the eyeglasses for less money than from a provider. The Plan denied your request. The Plan says coverage for eyewear is available through the network provider.Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a provider.We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you $150 for eyeglasses provided on April 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services (G0481) provided  on July 10, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation does not support 8 or more drug classes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0481 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed".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 drug testing services. Our reviewer says that the use of code G0481 is not supported by the records provided. Our physician reviewer found that only 6 drug classes were tested in the documentation provided.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 drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services (G0481) provided on July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 14, 2019 to September 14, 2019 by out of network 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 a non-participating 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on June 14, 2019 to September 14, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the tumor immunohistochemistry services rendered on May 29, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 88360 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 88360 (tumor immunohistochemistry)and 88381 (microdissection). Code 88360 is a column II code with a modifier indicator of 1 when billed with column I code 88381. Code 88360 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay for the tumor immunohistochemistry services rendered on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora hospital clinic visit (G0463) and the removal of a nail (11750) provided by the provider on April 16, 2019.You asked the Plan to waive the copayment fora hospital clinic visit and the removal of a nail. You say that the clinic is not in the hospital building.The Plan denied your request. The Plan says outpatient hospital services have a $275 copayment per visit in a hospital facility and a doctor visit with a specialist has a $25 copayment per visit.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 $275 copayment for outpatient hospital services and a $25 copayment for adoctor visitwith a specialist. You have been asked to pay a $275 copayment for a hospital clinic visit and a $25 copayment for a doctor visit with a specialist. These services fall within the outpatient hospital services and a doctor visit benefit category($275 + $25 = $300). 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 fora hospital clinic visit (G0463) and the removal of a nail (11750) provided on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided on February 16, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that this is medically necessary.The Plan denied your request. The Plan says medical records were not received.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crossesat least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. Despite multiple attempts by the plan, medical records were not received. It cannot be determined if the enrollee meet the criteria for these services. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay fortheacute inpatient hospital care provided on February 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waivethe $250 copayment charged for ambulance transport provided on July 4, 2019 by an out of network provider. You asked the Plan to waivethis copayment. You say that you had met your maximum out of pocket in April and this copayment should not apply.The Plan denied your request. The Plan says while you had met the out of maximum for in network care at the time of service, you had not met the total out of pocket maximum that included out of network providers.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 $250 copayment for each out of network ambulance transport one way. The information submitted by the Plan shows that you had not met the combing in and out of network out of pocket maximum at the time of service. Therefore, we decided that the Plan does not have to waivethe $250 copayment charged for ambulance transport provided on July 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forcervical, multiple postcollar, occipital/mandibular supports, adjustable (L0180) provided to the enrollee on July 31, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the enrollee has previously received the same items from the same provider that is still within the 5-year RUL.The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee has received the same orthosis from the same provider on May 21, 2018. This orthosis is still within the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the lumbar-sacral 
orthosis at issue. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay forcervical, multiple post collar, occipital/mandibular supports, adjustable (L0180) provided to the enrollee on July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on October 1, 2019.You asked the Plan to pay fo rthe services. The Plan denied your request. The Plan says the services were not authorized.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 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 medical services provided by an out-of-network provider on October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (an EGD) with biopsy (73239) and dilation of the esophagus (43450) provided on July 16, 2019.
You asked the Plan to waive the copayment for an EGD and dilation of the esophagus. You say that you were told if you paid upfront you would receive a discount and should only be liable for $240. You don't feel liable for the $25 bill you received. The Plan denied your request. The Plan says outpatient surgery has a $325 copayment in 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 a $325 copayment for outpatient surgery. You have been asked to pay a $25 copayment for an EGD and dilation of the esophagus. This service falls within the outpatient surgery benefit category. Your down payment plus a 20% discount ($240 + $60 = $300). Therefore, $300 + $25 remaining = $325. 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 esophagogastroduodenoscopy (an EGD) with biopsy (73239) and dilation of the esophagus (43450) provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe office visit and the endoscopy swallow provided on February 18, 2019.You asked the Plan to waive the copayments forthe office visit and endoscopy swallow. You say that the technician did the swallow test and the doctor gave you the results. You say that you are wondering why you were billed fortwo copayments.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 $40 copayment for services obtained from a specialist.You have been asked to pay a $40 copaymentfor the office visit and a $40 copayment for the endoscopy swallow. The office visit and endoscopy swallow fall within the "Physician/Practitioner services, including doctor's office visits" benefit category.The records show that you had two services by different providers.This means that you have been asked to pay the correct amount based on yourcontract 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 forthe office visit and the endoscopy swallow provided on February 18, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora screening mammography (77067-26) and digital breast tomosynthesis (77063-26) provided on February 4, 2019.You asked the Plan to pay for the screening mammography and digital breast tomosynthesis. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says the billed codes are duplicate claim lines. Based on Medicare billing criteria, duplicate claims are not eligible for payment.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 77067-26 is a screening mammography and 77063-26 is a digital breast tomosynthesis.We find that CPT codes 77067-26 and 77063-26 are not supported in the medical record. Specifically, each claim was billed as 77067-26 and 77063-26 which is duplicate billing. Codes 77067-26 and 77063-26 were already paid by the plan. Based on this information, we decided that Medicare rules for coverage of the screening mammography and digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay fora screening mammography (77067-26) and digital breast tomosynthesis (77063-26) provided on February 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided by an out-of-network provider, on August 21, 2019 to August 24, 2019.You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that your doctor told you to go to the hospital. You say that your doctor never asked what kind of insurance you had,The Plan denied your request. The Plan says the correct coinsurance 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 50% coinsurance for inpatient hospital care/out-of-network. You have been asked to pay less than a 50% coinsurance of the allowed amount for an inpatient hospital stay. The total allowed amount is $7,790.12. The total amount you are being asked to pay is $3,116.05 ($7,790.12 x 50% = $3,895.06). An inpatient hospital stay falls within the inpatient hospital care/out-of-network 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 inpatient hospital stay provided by an out-of-network provider, on August 21, 2019 to August 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to further pay forthe typhoid shot you received on October 25, 2018.You asked the Plan to further pay forthe typhoid shot. You say that the shot was given before travel to Cuba.The Plan denied your request. The Plan says you pay a 20% coinsurance for foreign travel immunizations.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for immunizations for foreign travel/occupational purposes. The file shows that you received a typhoid shot. The Plan has agreed to pay for the services at issue as a covered benefit. You have been asked to pay a 20% coinsurance for the typhoid shot. The service provided falls within the immunizations benefit category. This means that you have been asked to pay the correct amount based on your contract with thePlan. 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 further pay for the typhoid shot you received on October 25, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services (CPT 72170) provided to the enrollee on July 25, 2019.You asked the Plan to pay forthe services. You say that based on the hospital and radiology report, each of the procedures (CPT 72170) was performed at separate times to check the patient condition.The Plan denied your request. The Plan says CPT 72170 is the column II procedure to the column procedure already billed -CPT 73502.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Wefind that CPT code 72170 is not supported in the medical record. Specifically, this code is a column II procedure to the column I procedure already billed on this claim -CPT 73502. This code cannot be billed separately. 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 forradiology services (CPT 72170) provided on July 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foradvanced radiology services provided by "the hospital" on June 25, 2019.You asked the Plan to waive the copayment foradvanced radiology services. You say that your copayment should only be $30.The Plan denied your request. The Plan says the correct 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 $150 copayment for outpatient diagnostic tests/advanced radiology services. You have been asked to pay a $150 copayment for advanced radiology services. advanced radiology services fall within the outpatient diagnostic tests/advanced radiology services benefit category. Thismeans 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 foradvanced radiology services provided by "the hospital" on June 25, 2019.