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

We decided that the Plan does not have to waive the copayment for the laboratory work provided on October 24, 2019.You asked the Plan to waive the copayment for the laboratory work. You say that you had INR testing done and should not owe copayment. The Plan denied your request. The Plan says you have been charged 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 $5 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed for a urea nitrogen laboratory test.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 work provided on October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on October 31, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you cannot afford 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on October 31, 2019. The total allowed amount is $944.47 and 20% of that is $189. You have been asked to pay the total coinsurance amount of $189 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 provided on October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 31, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these 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 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 to the enrollee by an out-of-network provider on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-complete series x-rays (D0210) provided January 7, 2020.You asked the Plan to pay for the dental services. You say that you would like to appeal the denial because the provider had told you that you were due for this services.The Plan denied your request. The Plan says this service exceeds the benefit limit of once every 36 months (3 years).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. This service is allowed once every 36 months (3 years). Records show this service was provided March 14, 2018.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 for intraoral-complete series x-rays (D0210) provided January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on August 21, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that this is a medical necessity for lung rejections. You say that this service used to be covered.The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 forlab work provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fora specialist visit, a bone imaging study, and percutaneous vertebroplasty provided on October 2, 2019 and October 11, 2019.You asked the Plan to waive the copayments for a specialist visit, a bone imaging study, and percutaneous vertebroplasty. You say that you disagree with the out-of-area 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 $40 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $25 copayment for X-rays and a $275 copayment for outpatient hospital surgery services. You received a specialist visit on October 2, 2019. Therefore, you are responsible to pay the $40 copayment. You received a bone imaging study on October 2, 2019. Therefore, you are responsible to pay the $25 copayment. You received a percutaneous vertebroplasty on October 11, 2019. Therefore, you are responsible to pay the $275 copayment. The total amount you owe is: $340. You have been asked to pay the total copayment amount of $340 for a specialist visit, a bone imaging study, and percutaneous vertebroplasty. A specialist visit falls within the physician/practitioner services, includingdoctor's office visits benefit category. A bone imaging study and percutaneous vertebroplasty fall within the outpatient hospital 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 copayments fora specialist visit, a bone imaging study, and percutaneous vertebroplasty provided on October 2, 2019 and October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on October 16, 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 64480 is not supported.
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 64480 is injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure). We find that CPT code 64480 is not supported in the medical record. Specifically, there is no documentation of an injection of an anesthetic agent with imaging guidance was performed. 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 injection rendered on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional extractions provided on December 20, 2019.
You asked the Plan to pay for the two additional extractions. You say that you were not informed of the frequency limitation for these services. You also say that you do not have the money to pay for these. The Plan denied your request. The Plan says the benefits for this service had been satisfied and the frequency limitation had 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, extractions are limited to two procedures per calendar year. The record shows that you received four extractions on December 20, 2019, two of which were covered by the Plan, and your extractions benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the two additional extractions provided on December 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laryngoscopy services coded 31575 provided on August
5, 2019.
You asked the Plan to pay for the laryngoscopy 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 supported by the
documentation.
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 31575 is laryngoscopy, flexible; diagnostic.
We find that CPT code 31575 is not supported in the medical record. Specifically, the operative report did not
include documentation of a diagnostic flexible laryngoscopy. Based on this information, we decided that
Medicare rules for coverage of the laryngoscopy services have not been met. Therefore, we decided that the
Plan does not have to pay for the laryngoscopy services coded 31575 provided on August 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on January 27, 2020 through January 28, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9500 has a status code of I which is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9500 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9500 has a status code of I. This means that CPT code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided on January 27, 2020 through January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Privigen injection provided on September 19, 2019.You asked the Plan to waive the copayment forthese services. You say that you had met your out of pocket maximum in May of 2019.The Plan denied your request. The Plan says that cost shares are a contractual obligation and cannot be waived.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 the most you will have to pay out-of-pocket for in-network covered Part A and Part B services in 2019 is $2,900. You have been asked to pay a $250 copay for these services. The file indicates the plan reversed a claim from February 6, 2019. This claim reversal means that you had not yet met the out of pocket maximum of $2,900 and still owed a copay for the services received on September 19, 2019. 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 forthe Privigen injection provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with electrocardiographic recording (CPT 93229) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the external mobile cardiovascular telemetry with electrocardiographic recording provided out of network. You say that the requested out of network provider is the only company that your provider uses for heart monitors. You say that the requested service is medically necessary. The Plan denied your request. The Plan says in network clinicians and facilities are available for this same service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve external mobile cardiovascular telemetry with electrocardiographic recording (CPT 93229) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on September 11, 2019 to September 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. 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 skilled nursing services provided on September 11, 2019 to September 14, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 18, 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 the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy (97026) provided on September 19, 2019.
You asked the Plan to pay for the infrared therapy. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says this is a non-covered service and is not a
benefit when ordered by either a contracted or a non-contracted provider.
The Plan must follow Medicare rules. Medicare rules say that the use of infrared is non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the infrared therapy have not been met. Specifically, the use of infrared therapy devices is noncovered
per Medicare. Therefore, we decided that the Plan does not have to pay for infrared therapy (97026)
provided on September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60mg/ml Prolia.
You asked the Plan to pre-approve the Prolia. You say that you would like reconsideration as this drug is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says this drug is delivered to the physician's office by a specialty pharmacy who bills the member or health plan and therefore is not covered under part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve 60mg/ml Prolia.
Benefits for the Prolia 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography services (77067) provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the mammography services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were network providers available.
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 mammography services (77067) provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular expression testing provided on November 11, 2019 by an out of network (OON) provider.
You asked the Plan to pay for pathology services. You say that you are the only company that can do this test. The Plan denied your request. The Plan says 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 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 a molecular expression testing provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOtezla tablets.You asked the Plan to pre-approvethe Otezla tablets. The Plan denied your request. The Plan says the prescription drug, Otezla, is a Part D medication and those medications are not covered under the enrollee's plan.The Plan also says that the request indicates that medication is to be self-administered by the enrollee.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-approveOtezla tablets.Benefits for the Otezla tabletsmay be available under Medicare Part D.Contactthe 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 waive the copayment for a fine needle aspiration biopsy provided on October 23, 2019.
You asked the Plan to waive the copayment for a fine needle aspiration biopsy. You say that you thought that you would only owe a $150 copayment. 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 $150 copayment for non-surgical visits and a $275 copayment for surgical visits. You received a fine needle aspiration biopsy on October 23, 2019. A fine needle aspiration biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for a fine needle aspiration biopsy. A fine needle aspiration biopsy 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 a fine needle aspiration biopsy provided on October 23, 2019.