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

We decided that the Plan does not have to pay for laboratory testing provided on May 21, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because this provider is outof-
network with the Plan and the ordering provider is also out-of-network with the Plan.
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 laboratory testing provided on May 21, 2020 by an
out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation (D0140)
provided on November 11, 2020.
You asked the Plan to pay for the limited evaluation. You say that this was an urgently needed evaluation due
to a dislodged crown. The Plan denied your request. The Plan says they can only cover one limited oral
evaluation per year. The Plan already covered a limited evaluation for you in January, therefore this benefit has
been exceeded on the date of service.
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 evaluation requested exceeds the
frequency allowed covered under this benefit. The urgent nature of the situation does not change this.
Therefore, we decided that the Plan does not have to pay for the limited (problem-focused) oral evaluation
(D0140) provided on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from September 24, 2020, to October 31, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with how the claims were processed. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and a $160 copayment for days 21-47 for SNF care. The enrollee had a SNF stay from September 24, 2020, to October 31, 2020. The enrollee is not being charged a copayment for days 1-20 (September 24, 2020, to October 13, 2020). The enrollee is responsible to pay a $160 copayment for days 21-37 (October 14, 2020, to October 30, 2020). However, the enrollee is only being asked to pay $2,337.32, which is less than the total copayment amount. The enrollee has been asked to pay $2,337.32 for a SNF stay. A SNF stay falls within the SNF care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from September 24, 2020, to October 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on October 16, 2020.
You asked the Plan to waive the copayment for these services. You say that your physician ordered the tests to know your health condition. 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 $20 copayment for each in-network covered lab services.
Review of the file shows that you received laboratory services on October 16, 2020. Per the contract with the Plan, there is a $20 copayment for each in-network covered lab services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $19.90. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $19.90 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medication assisted treatment, methadone, (G2067) provided June 1, 2020 to August 27, 2020.
You asked the Plan to pay for Medication assisted treatment. You say that you were told to start treatment and pay out of pocket until your insurance kicked in and then later was told they did not accept your insurance after you were already treated. The Plan denied your request. The Plan says additional clinical, proof of payment and an itemized bill was not received.
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 G2067 is medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled opioid treatment program). We find that CPT code G2067 is not supported in the medical record. Specifically, additional information was requested. The record show that the plan made several attempts to obtain the additional information. Based on this information, we decided that Medicare rules for coverage of Medication assisted treatment have not been met. Therefore, we decided that the Plan does not have to pay for medication assisted treatment, methadone, (G2067) provided June 1, 2020 to August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of Prolia (a Medicare Part B drug) provided on January 20, 2021.
You asked the Plan to waive the coinsurance for Part B drug. You say that you were never informed that the provider ordered this instead of you ordering it from the pharmacy. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.
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 in-network Part B drug. The allowed amount of this claim is $1,206.60, resulting in a coinsurance obligation of $241.32. You have been asked to pay 20% coinsurance for Part B drug. Part B drug falls 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 an injection of Prolia (a Medicare Part B drug) provided on January 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on December 22, 2020.
You asked the Plan to waive the copayment for lab tests. You say that this lab work was for your annual visit so you should not be charged. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $10 copayment for lab tests. You have been asked to pay $10 copayment for lab tests. Lab tests fall 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 laboratory tests provided on December 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 15, 2020.
You asked the Plan to waive the copayment for ambulance services. 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 a $350 copayment for ambulance services. You have been asked to pay a $350 copayment for ambulance services. Ambulance services 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 ambulance services provided on June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the walker (E0135) provided December 27, 2020.
You asked the Plan to waive the deductible for the walker. You say that you would like the deductible waived due to extenuating circumstances. The Plan denied your request. The Plan says the cost share has processed correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible for durable medical equipment. The item or service you asked the Plan to waive the deductible for falls within the benefit category durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible for durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the walker was received on December 27, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the walker (E0135) provided December 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B Prescription drugs and medical supplies provided on November 20, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B Prescription drugs and medical supplies. You say that your EOC does not mention a coinsurance for outpatient surgery. The Plan denied your request. The Plan says the cost share was applied correctly. The Plan also says that cost sharing is a contractual obligation under the Plan 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 you must pay a 20% coinsurance for each Medicare-covered Part B drug for Medicare Part B Prescription Drugs, and a 20% coinsurance for each Medicare-covered medical supply for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The allowed amount of this claim totals $3,977.97 resulting in a total coinsurance amount of $795.59. You have been asked to pay a 20% coinsurance for each Medicare-covered Part B drug, and a 20% coinsurance for each Medicare-covered medical supply for the Medicare Part B Prescription drugs and medical supplies. Medicare Part B Prescription drugs and medical supplies falls within the Medicare Part B Prescription Drugs and Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit categories. 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 Prescription drugs and medical supplies provided on November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0428) provided on March 13, 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 $225 for Medicare-covered ambulance services per day. You have been asked to pay $225 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 (A0428) provided on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac resynchronization defibrillator pulse generator implantation rendered from March 11, 2020 to March 14, 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 not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that cardiac pulse generator implantation is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had symptomatic bradycardia and complete heart block. In addition, a transthoracic echocardiogram demonstrated an ejection fraction of 23.8 percent. Coronary arteries were not obstructed at the time of catheterization. The enrollee was
not receiving optimal medical therapy for three months prior to implantation. The services were 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 pay for the cardiac resynchronization defibrillator pulse generator implantation rendered from March 11, 2020 to March 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the durable medical equipment provided May 19, 2020, to August 19, 2020.
You asked the Plan to waive the coinsurance for the durable medical equipment. You say that because you did not use the equipment, you believe you should not be responsible for the cost. The Plan denied your request. The Plan says the cost share processed correctly and no reimbursement is due.
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 durable medical equipment. You have been asked to pay a total cost share of $136.82 for the durable medical equipment ($684.41 allowed amount x 20% coinsurance). The durable medical equipment falls within the durable medical equipment 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 the durable medical equipment provided May 19, 2020, to August 19, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health assessment rendered on December 15, 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 are not covered.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 96127 (behavioral health assessment) and G0439 (annual wellness visit). Code 96127 is a column II code with a modifier indicator of 1 when billed with column I code G0439. Code 96127 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the behavioral health assessment rendered on December 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services rendered from July 16,
2020 to July 23, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that PT services must be billed with modifier -GP.
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required -GP
modifier. 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 (PT) services
rendered from July 16, 2020 to July 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0427) provided on October 6, 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 $220 copayment for each one-way Medicare-covered ground ambulance trip provided. You have been asked to pay a $220 copayment for the one-way Medicare-covered ground 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 October 6, 2020.
Your complaint about the availability of the emergency room and transfer to another hospital for care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on February 24, 2020.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says the vision benefit is only available when the services are received from a network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by the Plan's optical provider.
We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the Plan's network vision provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 5, 2020.
You asked the Plan to pay for the knee orthosis and suspension sleeve. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this patient did not receive video or telephonic visit by the ordering physician in order to warrant the code(s) billed
The Plan must follow Medicare rules. Medicare rules say that a durable medical equipment provider is prohibited from making unsolicited phone calls to enrollees. We looked at the file and Medicare rules. In this case, the Plan has attested that the enrollee was contacted via an unsolicited phone call regarding the provision of the items at issue. Based on this information, we decided that Medicare rules for coverage of the knee orthosis and suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided November 29, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. 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 $60 copayment for Emergency Care. You have been asked to pay a $60 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 an emergency room visit (99283) provided November 29, 2020.