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

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 8, 2021.
You asked the Plan to waive the copayment for specialist services. You say that you believe this should be covered. 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 $35 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $35 copayment for specialist services. The correct copayment has been applied to the office visit that was provided. Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on January 21, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for observation services provided by a participating provider on April 5, 2021.
You asked the Plan to waive the coinsurance for observation services. You say that you stayed at the hospital overnight. 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 20% coinsurance for outpatient hospital observation.
You have been asked to pay a 20% coinsurance of the allowed amount for observation services. The total allowed amount is $10,791.31. The total amount you are being asked to pay is $2,158.26 ($10,791.31 x 20% = $2,158.26). Unless formally admitted to the hospital, an outpatient observation coinsurance will be applied, even in an overnight stay occurs. Observation services fall within the outpatient hospital observation 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 observation services provided by a participating provider on April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that imaging has demonstrated severe spinal stenosis at L2-L3 and L3-L4, the levels requested for treatment. The enrollee has more than two levels of disease at which operative intervention are indicated. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen supplies received on March 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the oxygen supplies. You say that you were not advised that these items would not be covered. The Plan denied your request. The Plan says the items received are not a covered benefit when provided by an OON 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 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 oxygen supplies received on March 4, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the imaging services rendered to you on July 6, 2020.
You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 $110 copayment for basic radiological services at an outpatient hospital, a $350 copayment for nuclear medicine services at an outpatient hospital, and a 20% coinsurance for chemotherapy drugs.
Review of the file shows that you received myocardial perfusion imaging (MPI) on July 6, 2020. You have been asked to pay a $110 copayment for these services. These services fall within the basic radiological services at an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received a transthoracic echocardiogram on July 6, 2020. You have been asked to pay a $350 copayment for these services. These services fall within the nuclear medicine services at an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received chemotherapy services on July 6, 2020. You have been asked to pay 20% coinsurance for these services, for a total of $35.35. These services fall within the chemotherapy services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $495.35. 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 cost sharing for the imaging services rendered to you on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), and the periodic oral evaluation (D0120) received April 7, 2021 from the out-of-network provider.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that you were told by the Plan that this provider was in-network. The Plan denied your request. The Plan says this provider is out-of-network. For services received out-of-network, you pay 100% of the cost.
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 when received out-of-network. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), and the periodic oral evaluation (D0120) received April 7, 2021 from the out-of-network provider.
Your complaint about being told by a Plan representative this your provider was in-network is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 15, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was 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 per visit for each outpatient surgery or procedure. You have been asked to pay a $250 copayment per visit for these services. these services falls within the each outpatient surgery or procedure 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 outpatient surgical services rendered on December 15, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the freestanding emergency room (ER) services rendered on January 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers services in freestanding emergency departments only if the emergency clinic is affiliated with a hospital. We looked at the file and Medicare rules. The provider is a freestanding ER not affiliated with a hospital. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the freestanding emergency room (ER) services rendered on January 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73222).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says insufficient documentation has been provided to support the request.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment We looked at the file and Medicare rules. No physician order was provided for the MRI. The plan contacted the provider and received no response. No medical records were submitted to support the requested MRI. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73222).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided by a participating provider on February 23, 2021.
You asked the Plan to waive the copayment for diagnostic radiology services. You say that you do not agree with this copayment. 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 $160 copayment for outpatient diagnostic tests/in-network/diagnostic radiology services. You have been asked to pay a $160 copayment for diagnostic radiology services. The correct copayment has been applied to the radiology services that were provided. Diagnostic radiology services falls within the outpatient diagnostic tests/in-network/diagnostic radiology 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 diagnostic radiology services provided by a participating provider on February 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment debridement provided on February 2, 2021.
You asked the Plan to reduce the copayment the debridement. You say that you believed you would have a $35 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for outpatient surgery or procedure. You have been asked to pay a $250 copayment for the debridement. The debridement falls within the "Outpatient hospital services" benefit category. The record shows the debridement is considered a service provided at an outpatient hospital.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment debridement provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 5, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 a laboratory setting; 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 drug testing rendered on November 5, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) the prophylaxis
(D1110) and the bitewing - four radiographic images (D0274) received March 23, 2021 from the Medicare optout
provider.
You asked the Plan to pay for the dental services. You say that your contract with the Plan says you should
only owe 50% coinsurance for the requested services. The Plan denied your request. The Plan says your
contract states that services received from a Medicare opt-out provider are not eligible for reimbursement and
you will be responsible for the full cost of the services.
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 when they are rendered by a provider who does not participate in
Medicare. We have verified that the provider in this case was opted out of Medicare on this date of service.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) the
prophylaxis (D1110) and the bitewing - four radiographic images (D0274) received March 23, 2021 from the
Medicare opt-out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the debridement provided on January 19, 2021.
You asked the Plan to reduce the copayment for the debridement. You say that you believed you would have a $35 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for outpatient surgery or procedure. You have been asked to pay a $250 copayment for the debridement. The debridement falls within the "Outpatient hospital services" benefit category. The record shows the debridement is considered a service provided at an outpatient hospital.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the debridement provided on January 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on March 2, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the debridement provided on December 22, 2020.
You asked the Plan to reduce the copayment for the debridement. You say that you believed you would have a $35 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for outpatient surgery or procedure. You have been asked to pay a $250 copayment for the debridement. The debridement falls 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. The record shows the debridement is considered a service provided at an outpatient hospital.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the debridement provided on December 22, 2020.