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

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 31, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you paid the $15 copayment and disagree with the additional 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 $45 copayment for specialist visits. You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on July 31, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the mental health care provided from September 29, 2020 to November 25, 2020.

You asked the Plan to waive the copayments for the mental health care. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received mental health services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient mental health care. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received mental health services from September 29, 2020 to November 25, 2020. You have been asked to pay a $40 copayment for each mental health visit, totaling $1440.00 for all visits. The mental health care falls within the Outpatient mental health care benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the mental health care provided from September 29, 2020 to November 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) observation care discharge day management services (99217) provided September 21, 2019 to September 22, 2019.

You asked the Plan to pay for the inpatient services. You say that due to the pandemic you had to close your office unexpectedly and your batch was rejected but the biller was away to take care of her mother who had COVID and now the claims are denied due to timely filing. The Plan denied your request. The Plan says this claim was received past the timely filing limitation.

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 a claim for the inpatient services was not filed until January 6, 2021. 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 initial observation care (99220) observation care discharge day management services (99217) provided September 21, 2019 to September 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on January 15, 2021.

You asked the Plan to pay for a limited oral evaluation. You say that you want the Plan to pay for this service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 limited oral evaluation (D0140) provided on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 22, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you thought that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for specialist visits. 

You had a specialist visit on January 22, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $20 copayment. 

You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on January 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for X-rays of the neck, spine, and pelvis (72040, 72070, 72100, 72170) provided on December 4, 2020, by an OON provider.

You asked the Plan to pay for X-rays of the neck, spine, and pelvis. You say that the requested services were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.

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 X-rays of the neck, spine, and pelvis (72040, 72070, 72100, 72170) provided on December 4, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit rendered on January 29, 2020.
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the deductible was applied correctly.
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 $185 yearly deductible for your combined in-network and out-of-network covered medical services. The item or service you asked the Plan to waive the deductible for falls within the in-network specialist's office visit for Medicare-covered vision services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $185 yearly deductible for your combined in-network and out-of-network covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on January 29, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit rendered on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that medical records prove the necessity of the service. The Plan denied your request. The Plan says a prior authorization was not obtained as required.

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 office visit provided on August 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for oncology office visits provided on January 30, 2020 and February 7, 2020.
You asked the Plan to waive the copayments for office visits. You say that you are aggravated with this provider and are on a limited income. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $50 copayment for each specialist visit. There were 2 visits, resulting in a total copayment amount of $100. You have been asked to pay $50 copayment for each office visit. Office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for oncology office visits provided on January 30, 2020 and February 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from February 5, 2020, through March 30, 2020.
You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physical therapy. 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 physical therapy provided from February 5, 2020, through March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular genetic screening panel testing provided on September 1, 2020.
You asked the Plan to pay for genetic testing. 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 Medicare denies coverage for all cardiovascular risk assessment panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, genetic testing, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular genetic screening panel testing provided on September 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the implantable heart monitor evaluation rendered on January 3, 2021.
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 $45 copayment for each Medicare-covered diagnostic test completed in an outpatient hospital.
Review of the file shows that you received a heart monitor evaluation on January 3, 2021. Per the contract with the Plan, there is a $45 copayment for each Medicare-covered diagnostic test completed in an outpatient hospital. 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 $34.37. Given that the allowed amount was less than the $45 copayment, you have been asked to pay $34.37 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the implantable heart monitor evaluation rendered on January 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation system for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.
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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. Furthermore, MRI addendum noted right lateral margin of the L5-S1 disc there is some endplate irregularity and also mild Modic Type III changes both in L5 and S1. The procedure is typically supported for Modic type I and II changes. Furthermore, three are multiple, plausible pathologic sources of significant pain generation. These plausible sources include other spinal levels (of intervertebral disc and/or spinal stenosis origin). There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Intracept intraosseous nerve ablation system at both L2/3 and L5/S1 levels is not medically reasonable or 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept intraosseous nerve ablation system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided by an out-of-network provider on August 3, 2020.

You asked the Plan to pay for the psychotherapy. You say that the provider depends on the hospital staff to verify eligibility and to obtain the proper authorization. You say that these were medically necessary services, and the claim should be reprocessed for payment at the maximum amount allowed. The Plan denied your request. The Plan says prior authorization was required but not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy provided by an out-of-network provider on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that this service was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 provided on December 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The file shows the enrollee was seen for knee and shoulder pain. 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 office visit provided on January 20, 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 application of hot or cold packs to 1 or more areas (97010) and manual physical therapy techniques to 1 or more regions (97140) provided October 8, 2020.
You asked the Plan to pay for the chiropractic services. You say that attached is the itemized bill requested for date of service 10/08/2020. Please review and process this claim for payment. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for application of hot or cold packs to 1 or more areas (97010) and manual physical therapy techniques to 1 or more regions (97140) provided October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on December 10, 2020.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says an eye refraction is not a covered benefit for a medical exam.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitoring feature (A9279) provided on September 11, 2020.

You asked the Plan to pay for the monitoring feature. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code A9279 has a status indicator of I and is not valid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code A9279 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code A9279 has a status indicator of I. This means that CPT code A9279 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the monitoring feature have not been met. Therefore, we decided that the Plan does not have to pay for the monitoring feature (A9279) provided on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic appliance (E0673) provided on November 13, 2020.

You asked the Plan to pay for a pneumatic appliance. You say that the requested item is a necessity for the enrollee. The Plan denied your request. The Plan says rules for a pneumatic appliance have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic appliance (E0673) provided on November 13, 2020.