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

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram services (77065, G0279) and ultrasound of the breast (76642) provided on November 20, 2020.
You asked the Plan to waive the deductible for the diagnostic imaging services. You say that you do not understand why you are being billed for this service. You believe it was provided as preventative care and should be covered at no cost to you. The Plan denied your request. The Plan says medical records show that you had a screening mammogram a few weeks prior to the diagnostic services on November 20, 2020. Screening services are often covered at no cost to you; however, deductibles and cost-sharing often apply to diagnostic services. In this case, you had not yet met your $750 annual deductible and the services provided were billed as diagnostic services which were supported with medical records. The deductible was applied correctly.
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 there is a $750 deductible for outpatient diagnostic imaging services. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic imaging services. A screening service, such as a mammogram, is typically covered once per year and is given when there is no symptoms or previous concerns of a disease or condition. Medical records and indicate that you had your screening prior to these services, and these were given as a follow-up for further investigation. Therefore, these services are diagnostic. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic imaging services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic imaging services were received on November 20, 2020.
Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram services (77065, G0279) and ultrasound of the breast (76642) provided on November 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Galantamine ER mg capsule for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Galantamine ER mg capsule for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit.

You asked the Plan to pay for the clinic visit. The Plan denied your request. The Plan says services rendered by non-participating 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 clinic 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 clinic visit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a duplex scan provided on November 5, 2020.
You asked the Plan to waive the copayment for a duplex scan. You say that your primary care physician gave you misinformation regarding the scan. 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 $125 copayment for each radiological diagnostic service. You have been asked to pay a $125 copayment for a duplex scan. A duplex scan falls 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 a duplex scan provided on November 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on October 1, 2020, to November 11, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were told that your copayment would be $175. 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 $350 copayment for outpatient surgery. You have been asked to pay a $350 copayment for an outpatient surgery. The total amount you are being asked to pay is $1,050 ($350 x 3 surgeries = $1,050). The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery 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 outpatient surgery provided by a participating provider on October 1, 2020, to November 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on October 20, 2020.
You asked the Plan to pay for dental services. You say that you were proceeding on the basis that if your dentist was out-of-network you would qualify for a reduced benefit. The Plan denied your request. The Plan says the denial of payment for these services is correct, because dental services are not covered when performed by an out-of-network provider.
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 because they were provided by an out-of-network dentist. Therefore, we decided that the Plan does not have to pay for dental services provided on October 20, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic ultrasound provided on September 24, 2020.
You asked the Plan to pay for the diagnostic ultrasound. 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 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
diagnostic ultrasound. 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 diagnostic ultrasound provided on September 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on October 26, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that the charges are too high. 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 $325 copayment for diagnostic radiology services. You have been asked to pay the allowed amount of $273.14, which is less than the $325 copayment for a CT scan. A CT scan falls 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 a CT scan provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) provided on October 1, 2020.
You asked the Plan to pay for the dental service. You say that the treatment plan was not explained to you thoroughly. You say that it was your understanding that your insurance covered everything and that you did not have to worry about procedures that were not covered. You say that you advised you did not want any services that were not covered. You also say that you cannot afford to pay for services that are not covered. The Plan denied your request. The Plan says gingivectomy or gingivoplasty to allow access for restorative procedure is not listed as a covered service. The Plan says that you have limited dental coverage and this service is clearly not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Evidence of Coverage clearly states that any services that are not listed are not covered. Therefore, we decided that the Plan does not have to pay for the gingivectomy or gingivoplasty to allow access for restorative procedure (D4212) provided on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the positioning cushion/pillow/wedge including all accessories provided August 28, 2020, to September 11, 2020.
You asked the Plan to pay for the positioning cushion/pillow/wedge. You say that the item was medically necessary and reasonable for your condition. The Plan denied your request. The Plan says this is a statutorily noncovered service because it is considered a precautionary device.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the positioning cushion/pillow/wedge including all accessories provided August 28, 2020, to September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of multi-layer compression system services
coded 29581 provided on May 14, 2020.
You asked the Plan to pay for the application of multi-layer compression system services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed
are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 29581 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the application of multi-layer compression
system services have not been met. Therefore, we decided that the Plan does not have to pay for the application
of multi-layer compression system services coded 29581 provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the knee brace provided on November 7, 2020.
You asked the Plan to waive the deductible for the knee brace. You say that you were surprised to have a deductible and would like it removed. 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. Your contract with the Plan says that there is a $250 deductible that applies towards durable medical equipment. The knee brace you asked the Plan to waive the deductible for falls within the "Prosthetic devices and related supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards the knee brace. This cost sharing is a contractual obligation that had not been met at the time the knee brace was received on November 7, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the knee brace provided on November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from July
24, 2020, to August 20, 2020.
You asked the Plan to waive the copayments for wound debridement. You say that you paid less in the past and
disagree with the way the charges are being billed. 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 $250
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.
You received wound debridement at an outpatient hospital facility from July 24, 2020, to August 20, 2020, for
a total of 4 services. Wound debridement is considered an outpatient surgical procedure. Therefore, you are
responsible to pay a $250 copayment per each visit. The total amount you owe is: $250 (copayment) x 4
(wound debridement services) = $1,000.
You have been asked to pay the total copayment amount of $1,000 for wound debridement. Wound
debridement falls within 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 copayments
for wound debridement provided from July 24, 2020, to August 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on October 2, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that you disagree with how the claim was
processed. 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 $15
copayment for basic radiological services provided in a primary care providers office.
You have been asked to pay a $15 copayment for an x-ray. An x-ray falls 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
an x-ray provided on October 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
October 1, 2020.
You asked the Plan to pay for the dental service. You say that the Plan only paid $68 for the services that you
received in March 2020. You say that the service in this case was received more than 6 months later. You also
say that this service should be covered. The Plan denied your request. The Plan says comprehensive oral
evaluations are covered once every 3 plan years. The Plan says that the frequency limit for this service has been
exceeded.
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 frequency limit for this service has
been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on
March 6, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation
(D0150) provided on October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided by a participating provider on September 21, 2020.
You asked the Plan to waive the copayment for an ECG. You say that this should be part of your annual wellness exam. 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 $30 copayment for outpatient diagnostic tests/non-radiological diagnostic services. You have been asked to pay $19.55 which is less than your copayment amount of $30 for an ECG. When additional services are provided during an office visit additional copayments can be applied; therefore, the correct copayment has been applied. An ECG falls within the outpatient diagnostic tests/non-radiological diagnostic 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 an ECG provided by a participating provider on September 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology testing provided to the enrollee on
February 28, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request.
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes
will be considered part of the same panel.
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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there was no specific clinical rationale for the obtained laboratory studies. Procedures reported together
must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician
who is treating the beneficiary and using the results in the management of the beneficiary's specific medical
problem. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be
reported for the procedure. Medicare denies coverage when a laboratory assays two or more genes in a patient
in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single
procedural service, so one HCPCS codes must be submitted for the panel.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for molecular pathology testing provided to the enrollee on February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on November 30, 2020.
You asked the Plan to pay for a CT scan. You say that the enrollee had multiple exams on this date. The Plan denied your request. The Plan says this is not separately payable without a modifier.
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, we have confirmed that 70450 bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (70450) provided on November 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (99349, 94760, 99490) provided on
November 17, 2020, by an OON provider.
You asked the Plan to pay for the home health services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the services were provided without prior authorization and did not
meet criteria for OON coverage.
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 home health services (99349, 94760, 99490)
provided on November 17, 2020, by an OON provider.