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

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on March
17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for these services. You say that the cost is a financial hardship. The Plan denied your
request. The Plan says the services were rendered by an out-of-network 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 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 magnetic resonance imaging (MRI) provided
on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on February 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an OON office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 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 an office visit (99214) provided on February 15, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on abscess drainage procedures (27301, 27603) provided on March 12, 2021.

You asked the Plan to pay for surgical assistant services. You say that the surgical assistant was requested by the operating surgeon. The Plan denied your request. The Plan says surgical assistant services are not covered for these procedures.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) codes 27301 and 27603. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on abscess drainage procedures (27301, 27603) provided on March 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of head and neck (76536) ultrasound, retroperitoneal, real time with image documentation (76775) provided by November 9, 2020.

You asked the Plan to waive the copayment for the diagnostic service. You say that you are objecting the radiology copay of $50 because these images were requested by your PCP. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $50 copayment for basic radiological services in a freestanding radiological facility. 

You have been asked to pay $50 copayment for the diagnostic service. The diagnostic service 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 the ultrasound of head and neck (76536) ultrasound, retroperitoneal, real time with image documentation (76775) provided by November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, and bitewing x-rays provided on March 9, 2021.

You asked the Plan to pay for the intraoral periapical x-rays and bitewing x-rays. You say that you were told by the dentist that it is necessary to have radiographic images before a tooth extraction. The Plan denied your request. The Plan says intraoral periapical x-rays are not a covered benefit. The Plan also says that your benefits for bitewing x-rays have been satisfied and the frequency limitation 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, intraoral x-rays are not among those covered under this benefit. The contract says that bitewing x-rays are limited to one set per calendar year. The record shows that you received two sets of bitewing x-rays on March 9, 2021, one of which was covered by the Plan, and your bitewing x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, each additional intraoral periapical x-ray, and bitewing x-rays provided on March 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from January 4, 2021, through January 6, 2021.

You asked the Plan to waive the coinsurance for radiation therapy. You say that you made your full out-of-pocket amount payment and the hospital said that would complete your 7 weeks of coverage. You say that it is not your fault your last 3 treatments carried over into 2021 and the payments should be processed. The Plan denied your request. The Plan says the coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for radiation therapy at an in-network provider.

You have been asked to pay $344.18, which is 20% of the allowed amount for radiation therapy. The allowed amount is $1,720. 82 (20% x $1,720. 82 = $344.18). Radiation therapy 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 coinsurance for radiation therapy provided from January 4, 2021, through January 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on April 7, 2021 by an OON provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services were not referred by a network provider or rendered in a participating facility. The Plan also says that the services were not approved in advance.

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 the domiciliary or rest home visit provided on April 7, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), a core buildup (D2950), and fillings
(D2331, D2392) provided on March 15, 2021.

You asked the Plan to pay for a crown, a core buildup, and fillings. You say that you were not aware your plan
had changed, and you want the Plan to pay for these services. The Plan denied your request. The Plan says the
services at issue are not covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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 a crown
(D2740), a core buildup (D2950), and fillings (D2331, D2392) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous infusion, for therapy, prophylaxis, or diagnosis (96365), additional sequential infusion of a new drug/substance up to one hour (96367), intravenous infusion, hydration; each additional hour (96361), infusion, normal saline solution (J7030), injection, dexamethasone sodium phosphate (J1100), and the injection, odansetron hydrochloride (J2405) rendered by the out-of-network (OON) provider on January 19, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 intravenous infusion, for therapy, prophylaxis, or diagnosis (96365), additional sequential infusion of a new drug/substance up to one hour (96367), intravenous infusion, hydration; each additional hour (96361), infusion, normal saline solution (J7030), injection, dexamethasone sodium phosphate (J1100), and the injection, odansetron hydrochloride (J2405) rendered by the out-of-network (OON) provider on January 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on September 10, 2020.

You asked the Plan to pay for the laboratory test. You say that the records should be reviewed, and the claim should be processed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory test provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services received on March 11,
2021.

You asked the Plan to waive the copayment for the services. You say that the nurse didn't help. The Plan
denied your request. The Plan says that you agree that the services were rendered, which is supported by the
medical records.

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 $45
copayment for Medicare-covered visits with a specialist.

You have been asked to pay a $45 copayment for the services. The services fall within the Medicare-covered
visits with a 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 podiatry
services received on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Part B medication and its administration provided on February 12, 2021.

You asked the Plan to waive the cost share for the Part B medication and its administration. You say that there must be confusion with the billing. You say the copayment is too high. 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 20% coinsurance for each in-network Medicare-covered Part B drugs and a $35 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.

You have been asked to pay $356 which is 20% of the allowed amount for the Part B medication. The allowed amount is $1,780. ($1,780 x 20% = $356). You have been asked to pay a $14.46 copayment, which is less than the standard copayment amount, for the medication's administration. The Part B medication falls within the "Medicare Part B Prescription Drugs" benefit category. The drug's administration falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record shows the provider is out-of-network, but the claim was processed under the in-network benefits.

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 cost share for the Part B medication and its administration provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87496, 87498, and 87631 provided on April 20, 2020.

You asked the Plan to pay for the laboratory services. You say that you feel these services should be covered. 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.

We find that CPT codes 87496, 87498, and 87631 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 32. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87496, 87498, and 87631 provided on April 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance transportation
(A0429, A0425) provided on February 26, 2021.

You asked the Plan to waive the copayment for emergency ambulance transportation. You say that you have
never had to pay these charges before, and you feel that it should be covered by the Plan. 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 $300
copayment for ambulance services.

You have been asked to pay a $300 copayment for emergency ambulance transportation. The services at issue
fall within the ambulance services benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for emergency ambulance transportation (A0429, A0425)
provided on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the coinsurance for the disposable contact
lenses (S0500) and the sales tax provided on April 16, 2021.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the item provided.

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 any
amount over the $100 retail price for frames and lenses.

The Plan allowance is a $100 (combined in and out of network) benefit toward the purchase and fitting of
eyeglasses and pair of lenses or contact lenses (1 per calendar year).

You have been asked to pay $196.76 ($279. 96-$100=$179.96 + $16.80 tax) for the contact lenses provided.
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 issue reimbursement of the coinsurance for the disposable contact lenses (S0500) and
the sales tax provided on April 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0261).

You asked the Plan to pre-approve the semi-electric hospital bed. You say that the bed is medically necessary.
The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 the semi-electric hospital bed. Our
reviewer says that the semi-electric hospital bed is not medically necessary. Our physician reviewer found the
enrollee does not require frequent changes in body position. There is no need for immediate changes in body
position. The enrollee's condition does not require special attachments that cannot be fixed and used on an
ordinary bed.

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 semi-electric hospital bed have not been met. Therefore, we decided that the
Plan does not have to pre-approve a semi-electric hospital bed (E0261).
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90837) provided on December 15, 2020.

You asked the Plan to pay for psychotherapy services. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has failed to substantiate what necessary criteria the provider has not met. We found that the provider is licensed in the state where the services were performed and is certified by Medicare. There is no compelling evidence why the provider should not receive payment for the services rendered. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837) provided on December 15, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 12, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 12, 2020