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

We decided that the Plan does not have to waive the copayment for an oncology office visit provided on March 18, 2020.
You asked the Plan to waive the copayment for specialist visit. You say that you would like this copayment waived. 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 $15 copayment for specialist visit. You have been asked to pay $15 copayment for specialist visit. 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 an oncology office visit provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and bitewing x-rays rendered on March 18, 2021.
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.
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 limited oral evaluation and bitewing x-rays rendered on March 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on March 16, 2021.
You asked the Plan to waive the copayment for the eye exam. You say that this was your annual routine eye exam and you were charged $45. You say that your EOC doesn't state that you had to use an in-network provider. The Plan denied your request. The Plan says the copayment 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 $45 for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye.
You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show cataracts, vitreous detachment and myopia were discussed during the exam which is not considered routine. 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 eye exam provided on March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the odontoplasty, per tooth (D9971) provided January
18, 2021.
You asked the Plan to pre-approve the dental services. You say that the procedure was to correct a pain in your
mouth not for cosmetic reasons. The Plan denied your request. The Plan says this service is not covered under
the Plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract
specifically says that any service not listed on the list of covered dental procedures is not covered.
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 pre-approve the
odontoplasty, per tooth (D9971) provided January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on April 7, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you were advised you should receive this x-ray. The Plan denied your request. The Plan says this service is not covered under your 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, 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
panoramic x-ray (D0330) provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on
January 11, 2021.
You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies
coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic
patients with suspected or documented cardiovascular-respiratory disease.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or
documented cardiovascular-respiratory disease.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the cardiovascular risk assessment testing have not been met. Specifically, this is not a covered
benefit as Medicare denies coverage for all cardiovascular risk assessment testing except for the basic lipid
panel. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing
provided on January 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on April 7, 2021.
You asked the Plan to waive the copayment for these services. You say that the services should be covered. 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 $10 copayment for Medicare-covered lab services.
Review of the file shows that you received laboratory services on April 7, 2021. You have been asked to pay a $10 copayment for these services. These services fall within the Medicare-covered lab 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 laboratory services rendered on April 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, tomographic (SPECT); single study, at rest or stress (78452) provided September 10, 2020 to September 11, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you did not know the hospital was out of network and the claim should be covered. The Plan denied your request. The Plan says network status does not change the copayment amount. The claim was processed with the correct copayment applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $225 copayment for Medicare covered diagnostic procedures and tests.
You have been asked to pay $225 copayment for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for myocardial perfusion imaging, tomographic (SPECT); single study, at rest or stress (78452) provided September 10, 2020 to September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and pneumatic appliance (E0673) provided on February 5, 2021.
You asked the Plan to pay for a pneumatic compression device and pneumatic appliance. You say that you do not have the money to pay the charge for the items at issue. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The file does not show that you have lymphedema and/or chronic venous insufficiency with venous stasis
ulcers. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675)
and pneumatic appliance (E0673) provided on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 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 the claims were 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 13. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on February 4,
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 97530 is 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the
services were performed in the home setting and there is a more appropriate code for these services.
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 occupational therapy services rendered on
February 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on September 29, 2020.
You asked the Plan to pay for physical therapy. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if the service is not available from a preferred provider. You say that many services were not available on an outpatient basis due to the pandemic and the claim should be processed for payment at the in-network benefit. The Plan denied your request. The Plan says the billed code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner. As such, PT services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy provided on September 29, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97110) provided on March 11,
2020.
You asked the Plan to pay for physical therapy services. You say that this should be covered as an in-network
service. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a
physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to
requirements must be met, even though the service is provided by a licensed therapist who may perform the
services unsupervised in other settings.
We looked at the file and Medicare rules. The services at issue were billed by a nurse practitioner (NP), but
there is no evidence that the billing NP was on site while the services were being rendered. Based on this
information, we decided that Medicare rules for coverage of physical therapy services have not been met.
Therefore, we decided that the Plan does not have to pay for physical therapy services (97110) provided on
March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, intraoral x-ray and unspecified
preventive procedure provided on March 25, 2021 and the crown, core buildup, unspecified periodontal
procedure and unspecified preventive procedure provided on March 3, 2021.
You asked the Plan to pay for the limited oral evaluation, intraoral x-ray and unspecified preventive
procedures, crown, core buildup and unspecified periodontal procedure. You say that you didn't realize you
would be charged for this service. You say that your finances are few and need help solving this bill. The Plan
denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation, intraoral x-ray and unspecified preventive procedure provided on March 25, 2021 and
the crown, core buildup, unspecified periodontal procedure and unspecified preventive procedure provided on
March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation provided on April 7, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that the doctor explained that a specific type of x-ray was needed to see the extent of the bone loss before treatment could be recommended. You say that the denial should be reviewed. The Plan denied your request. The Plan says the service 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 the cone beam CT capture and interpretation provided on April 7, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 27, 2021.
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 99291 is 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of the first 30-74 minutes of critical care services spent on the enrollee.
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 critical care services rendered on February 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245) and two retainers (D6548 x2) provided on February 18, 2021.
You asked the Plan to pay for the pontic and retainers. You say that you were not advised that the Plan only covers temporary retainers before you received these services. The Plan denied your request. The Plan says these services are not covered under 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, 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 pontic (D6245) and two retainers (D6548 x2) provided on February 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70480) provided on April 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 70480 is part of an edit pair with procedure code 70450. Procedure code 70450 is a column one code, and procedure code 70480 is a column two code. Procedure code 70450 has been billed on this date of service, which means that procedure code 70480 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (70480) provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provide on July 4, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel.
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 test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any clinical information to verify why this testing was ordered or how it would affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the laboratory services provide on July 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on January 5, 2021, to March 30, 2021.
You asked the Plan to waive the copayment for an outpatient surgery. You say that this is too expensive. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery.
You have been asked to pay a $300 copayment for an outpatient surgery. The total amount you are being asked to pay is $1,500 ($300 x 5 surgeries = $1,500). The services that were provided are considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls within the outpatient surgery 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 outpatient surgery provided by a participating provider on January 5, 2021, to March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for adhesive remover, wipes, any type, each
(A4456) skin barrier, wipes or swabs, each (A5120) housing and integrated adhesive, for use in a tracheostoma
heat and moisture exchange system and/or with a tracheostoma valve, each (A7508) provided December 14,
2020 to April 9, 2021.
You asked the Plan to waive the copayment for the medical supplies. You say that you are requesting
reimbursement and future payment for Provox medical products. The Plan denied your request. The Plan says
the claims were processed with the correct cost shares applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Durable medical equipment (DME) and related supplies.
You have been asked to pay $334 coinsurance for the medical supplies. The medical supplies fall within the Durable medical equipment (DME) and related 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 adhesive remover, wipes, any type, each (A4456) skin barrier, wipes or swabs, each (A5120) housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each (A7508) provided December 14, 2020 to April 9, 2021