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

We decided that the Plan does not have to pay for the laboratory services rendered on May 2, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment applied to a mammogram provided on October 23, 2020.

You asked the Plan to waive the copayment applied to the mammogram. You say that the member help team advised you that the mammogram services would be covered. The Plan denied your request. The Plan says the copayment in dispute was appropriately applied to the mammogram 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 $40 copayment for routine radiology services. 

You have been asked to pay a $40 copayment for the mammogram. The diagnostic mammogram you received falls within the routine radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment applied to a mammogram provided on October 23, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department services provided on October 9, 2020.

You asked the Plan to waive the copayment for the emergency department services. You say that you only went to the emergency department to get a medication list from your cardiologist. The Plan denied your request. The Plan says you were charged this copayment 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 $125 copayment for Emergency Care. 

You have been asked to pay a $125 copayment for the emergency department services. The emergency department services fall within the Emergency Care benefit category. The charges submitted indicate services were done. 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 department services provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 7, 2020.

You asked the Plan to pay for the knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says there are no records of the physician ever seeing the enrollee.

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 the knee orthosis (L1833LT) and suspension sleeve (L2397LT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on September 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on September 28, 2020.

You asked the Plan to waive the copayment for an ECG. You say that you did not receive an ECG on this date of service and disagree with 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 $20 copayment for an ECG provided in a physician's office. 

The medical records show that you received an ECG provided on September 28, 2020. Therefore, you are responsible to pay the $20 copayment. 

You have been asked to pay a $20 copayment for an ECG. An ECG 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 an ECG provided on September 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 18, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 laboratory services. 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 laboratory services provided on September 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services (A0429) received on September 30, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you were admitted with COVID-19. The Plan denied your request. The Plan says you were charged this cost sharing 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 $275 copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $275 for these services. 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 services (A0429) received on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with a specialist (99214) provided on October 8, 2020.

You asked the Plan to waive the copayment for the specialist visit. You say that this was an annual visit to your gynecologist and should have no additional cost to you. The Plan denied your request. The Plan says the service was billed as an office visit with a specialist.

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 in-person office visit. 

You have been asked to pay a $45 copayment for the specialist visit. The provider in question specializes in gynecology and the service was billed as a standard office visit. This service falls within the specialist in-person office visit 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 office visit with a specialist (99214) provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on August 26, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says if the enrollee needs medical care that Medicare requires our plan to cover, and the providers in our network cannot provide this care, the enrollee can get this care from an out-of-network provider. The medical care will be coordinated for the enrollee with an out-of-network provider. Prior authorization from our plan must be obtained PRIOR to obtaining services.

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 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 physician's services that you provided on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prophylaxis provided on October 22, 2020 by an OON provider.

You asked the Plan to pre-approve the prophylaxis. You say that a Plan representative advised you that this provider was in-network. You also say that you contacted the provider and were told that they accepted your insurance. The Plan denied your request. The Plan says this service was rendered by an OON provider.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve the prophylaxis provided on October 22, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, with no transport (A0998) provided on August 26, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy or by Medicare as you were not transported by the ambulance.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on August 26, 2020. The ambulance benefit is a transportation benefit. When there is no transport by the billing party, neither Medicare nor the Plan pays for the service provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, with no transport (A0998) provided on August 26, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 9, 2020.

You asked the Plan to pay for the ambulance services. You say that your cardiologist told you to call for this service. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 9, 2020. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy services (97110, 97140) provided on November 6, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you need to complete several sessions of physical therapy and cannot afford the copayments. The Plan denied your request. The Plan says there is a $35 copayment for physical therapy.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient rehabilitation services. 

You have been asked to pay a $35 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation 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 physical therapy services (97110, 97140) provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and crown provided on September 10, 2020.

You asked the Plan to pay for the preventive procedure and crown. You say that you were aware that this provider had opted out of Medicare. You also say that you understood there were no networks under your insurance, and thought services rendered by this provider would be covered. The Plan denied your request. The Plan says the treating provider had opted out of Medicare effective April 1, 2020, to April 1, 2022. services performed by a privately contracted provider are not covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The record shows that you signed a private contract with the opt out provider stating you were aware that claims would not be able to be submitted to Medicare for payment. Therefore, we decided that the Plan does not have to pay for the preventive procedure and crown provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (95940, 95941), the unlisted neurological or neuromuscular diagnostic procedure (95999), the electroencephalogram (EEG) during surgery (95955), the somatosensory testing (95938), and the nerve conduction studies (95908) provided on March 5, 2019.

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 are not payable as the claim was submitted untimely.

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 these services was not filed until July 30, 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 continuous intraoperative neurophysiology monitoring (95940, 95941), the unlisted neurological or neuromuscular diagnostic procedure (95999), the electroencephalogram (EEG) during surgery (95955), the somatosensory testing (95938), and the nerve conduction studies (95908) provided on March 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services (97140, 97110) provided on November 2, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you need to complete several weeks of therapy and cannot afford the copayments. The Plan denied your request. The Plan says each session of outpatient therapy has a $35 copayment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient rehabilitation services. 

You have been asked to pay a $35 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation 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 the physical therapy services (97140, 97110) provided on November 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on September 15, 2020.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that you disagree with the charges because you have never been charged a copayment for diagnostic mammograms in the past. 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 routine radiology. 

Due to the diagnostic codes submitted with the claim, the mammogram you received on September 15, 2020, is considered diagnostic, not preventative. Therefore, you are responsible to pay the $45 copayment. 

You have been asked to pay a $45 copayment for a diagnostic mammogram. A diagnostic mammogram 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 a diagnostic mammogram provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on September 29, 2020.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says authorization was not obtained by the provider or the facility.

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 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 diagnostic radiology services provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for the vision care services (92134, 67028) and compounded drug (J7999) provided March 31, 2020.

You asked the Plan to waive the cost-sharing for the vision care services and compounded drug. You say that you should not have been charged an additional coinsurance for the compounded drug. The Plan denied your request. The Plan says the copayment and coinsurance were applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care and a 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a total of $53 for the services provided on March 31, 2020. This total amount includes a $20 copayment for vision care services and $33 cost-share for the compounded drug ($165 x 20% = $33). The vision care services fall within the Vision Care benefit category and the compounded 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 cost-sharing for the vision care services (92134, 67028) and compounded drug (J7999) provided March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on September 22, 2020.

You asked the Plan to pay for the subsequent nursing facility care. 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 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 subsequent nursing facility care provided on September 22, 2020.