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

We decided that the Plan does not have to waive the copayment for the ambulance service (A0427) provided on August 22, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $350 for Medicare-covered ambulance services per trip. You have been asked to pay $350 for the ambulance service 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 waive the copayment for the ambulance service (A0427) provided on August 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you eyeglasses provided on December 9, 2020.
You asked the Plan to reimburse you the eyeglasses. The Plan denied your request. The Plan says that the Plan processed the reimbursement request and sent a check in the amount of $125 to you on February 9, 2021.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan reimbursed you the eyewear benefit allowance of $125 for the eyeglasses. Therefore, we decided that the Plan does not have to reimburse you eyeglasses provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on September 16, 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 99203 is not separately payable.
The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the
same specialty must bill and be paid as though they were a single physician.
We looked at the file and Medicare rules. The file shows that procedure code 99222 (initial hospital care) was
billed and paid by the Plan on the same date of service as code 99203 (office visit) by the same physician. Code
99203 is not separately payable. Therefore, we decided that the Plan does not have to pay for the office visit
rendered on September 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says the enrollee does not have a history of failure, contraindication, or intolerance to the formulary alternatives: Synvisc/Synvisc-One, Durolane, and Gelsyn-3. The Plan also says that this is not a continuation of therapy in the past 365 days.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Gel-One. Our reviewer says that Gel-One (J7326) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drugs Synvisc/Synvisc-One, Durolane, and Gelsyn-3 before they will approve the requested drug. Our reviewer found that the enrollee has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on January 19, 2021.
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. 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 $100 copayment per day for other outpatient procedures and services, including outpatient surgery, performed in an outpatient hospital or ambulatory surgical center.
Review of the file shows that you received outpatient surgical services to your wrist on January 19, 2021. You have been asked to pay a $100 copayment for these services. These services fall within the other outpatient procedures and services, including outpatient surgery, performed in an outpatient hospital or ambulatory surgical center 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 January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257) provided November 24, 2020.
You asked the Plan to pay for the hearing aids. You say that you were told the Plan would pay $800 towards the hearing aids. The Plan denied your request. The Plan says the $800 allowance has already been applied to the claim.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids up to an $800 allowance. We looked at the file and the Plan's rules. The Plan provided documentation showing that the $800 allowance has already been applied to the claim. You are responsible for the remaining cost of the hearing aids. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5257) provided November 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from December 10, 2020, through December 15, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services 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 a $290 copayment each day for days 1 to 5 for Medicare-covered hospital care. You have been asked to pay $1,450 ($290 x 5 days) for the inpatient hospital care 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 waive the copayment for the inpatient hospital care provided from December 10, 2020, through December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 3, 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355), the filling (D2391), and
the scaling and root planing (D4341 x 2) provided from June 26, 2019, to August 6, 2019.
You asked the Plan to pay for the dental services. You say that you were never advised that you could apply for
reimbursement. You say that you were not aware of this until December 2020. You say that you sent the bill
immediately upon finding this out. You say that you would like for some of your costs from 2019 to be
recovered. The Plan denied your request. The Plan says you must submit your claim within 12 months of the
date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that the claims for these dental services were not filed until December 11, 2020. This means
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we
decided that the Plan does not have to pay for the full mouth debridement (D4355), the filling (D2391), and the
scaling and root planing (D4341 x 2) provided from June 26, 2019, to August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical/thoracic epidural injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found that you have neck and arm pain but no clearly defined neurological deficit. You had a spinal cord stimulator (SCS) in place, but the level is not specified. There is no documentation of visual or verbal analog scale pain scores. There is no documentation of recent physical therapy, chiropractic therapy, or a home exercise program. It is especially important to delineate where the SCS is placed, as it is contraindicated to place any epidural solutions near active SCS leads. Further, there is no documentation of recent conservative therapy or pain scores. The epidural is therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a cervical/thoracic epidural injection.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 22, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the 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 $50 copayment for emergency services in an in-network emergency room. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" 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 emergency room visit provided on October 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency problem-focused oral evaluation (D0140) provided on October 22, 2020.
You asked the Plan to pay for the problem-focused evaluation. You say that you feel this service should be covered as it was necessary. The Plan denied your request. The Plan says you had another limited oral exam to evaluate a problem in February. This service can only be covered once every 12 months. Therefore, the benefit for this service had been exhausted by the date of service in question.
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 limited evaluation is requested in a frequency not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the emergency problem-focused oral evaluation (D0140) provided on October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s) (75635) provided on November 17, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 a $325 copayment for Medicare-covered diagnostic radiology services. You have been asked to pay $213.58 for the diagnostic radiology service provided. This amount is the Plan allowed amount and is less than the applicable copayment for this service. 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 computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s) (75635) provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on July 15, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye exam provided on November 30, 2020.
You asked the Plan to pay for the routine eye exam. The Plan denied your request. The Plan says you have exceeded the calendar year maximum for this benefit.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers for one routine eye exam each calendar year. We looked at the file and the Plan's rules. The file shows that the Plan previously covered a routine eye exam on February 3, 2020. Based on this information, we decided that the Plan's rules for coverage of the routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye exam provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 21, 2020.
You asked the Plan to pay for the bitewing x-rays. You say that you were not aware that this would not be covered. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on December 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on July 2, 2020.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says the denied codes remain 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. We find that CPT code 80307 and HCPCS G0482 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services rendered on September 28, 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 codes J7050 and Q9967 are 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 J7050 is infusion, normal saline solution, 250 cc. The definition of code Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml. We find that CPT codes J7050 and Q9967 are not supported in the medical record. Specifically, there is no documentation of normal saline solution infusion at 250 cc to support code J7050. There is no documentation of a low osmolar contrast material to support code Q9967. 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 infusion services rendered on September 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services rendered on October 20, 2020.
You asked the Plan to waive the copayment for these services. You say that you had a catheter issue resulting from an earlier surgery. 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 $90 copayment per visit for Medicare-covered emergency care.
Review of the file shows that you received ER services on October 20, 2020. You have been asked to pay a $90 copayment per visit for these services. These services fall within the Medicare-covered emergency care 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 emergency room (ER) services rendered on October 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on
December 10, 2020.
You asked the Plan to pay for the dental services. You say that you are unemployed. You say that you cannot
afford to pay this bill. You say that you have gone to this provider for years. You also say that the Plan has
always paid him. The Plan denied your request. The Plan says the provider in this case is out of network. The
Plan also says that dental services that you receive out of network are 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 and the services are listed as covered,
the requested items or services are not among those covered under this benefit when they are performed out of
network. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis
(D1110) provided on December 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 19, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that the Plan only paid for two periodontal maintenance (D4910) services. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
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, periodontal maintenance (D4910) is limited to three procedures per plan year. The record shows that you received periodontal maintenance (D4910) services on February 17, 2020, May 18, 2020, and August 6, 2020 and your periodontal maintenance (D4910) benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 19, 2020.