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

We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EKG and an ultrasound provided by an in-network provider on September 20, 2019 to October 24, 2019. 
 
You asked the Plan to waive the copayment for an EKG and an ultrasound. You say that you cannot afford these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $20 copayment for outpatient diagnostic tests/in-network/non-radiological diagnostic and a $100 copayment for outpatient diagnostic tests/in-network/radiological diagnostic service.  
 
You have been asked to pay $16.20 which is less than your copayment amount of $20 copayment for an EKG and a $100 copayment for an ultrasound. The total amount you are being asked to pay is $116.20 ($100 + $16.20 = $116.20). An EKG falls within the outpatient diagnostic tests/in-network/non-radiological diagnostic services benefit category and an ultrasound falls within the outpatient diagnostic tests/in-network/radiological diagnostic service 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 EKG and an ultrasound provided by an in-network provider on September 20, 2019 to October 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating facility on October 22, 2019.You asked the Plan to waive the copayment fora diagnostic colonoscopy. You say that this was a screening. You say that this should be free. 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 a diagnostic colonoscopy. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy 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 a diagnostic colonoscopy provided by a participating facility on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 26, 2019.
You asked the Plan to pay for an office visit. You say that this is a payable service. The Plan denied your request. The Plan says payment for this service is included in the global surgical package.
The Plan must follow Medicare rules. Medicare rules say that preoperative visits are included in the global surgical package. We looked at the file and Medicare rules. The record shows that this office visit took place the day before the surgical procedure 38740, which has a global period of 090 indicating a major procedure, was performed by the same physician. This means that the office visit at issue is included in the global surgical package. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on October 13, 2019 by an out of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that the oxygen concentrator was medically necessary. The Plan denied your request. The Plan says you did not request 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 has network providers available who can provide 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 oxygen concentrator provided on October 13, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care provider visit provided on January 27, 2020.
You asked the Plan to waive the copayment for a primary care provider visit. You say that you 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 $5 copayment for primary care provider visits. You have been asked to pay a $5 copayment for a primary care provider visit. A primary care provider 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 primary care provider visit provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required, provided on November 20, 2019. 
 
You asked the Plan to pay for the core buildup. You say that the provider's office contacted the Plan prior to the services being rendered, and they were told that you had $1,280 of your annual maximum remaining. You also say that the provider said the service would be covered. The Plan denied your request. The Plan says you had exceeded your maximum benefit. The Plan also says that you reached the annual maximum on November 20, 2019 when processing this claim for the services rendered. 
 
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 Plan offers a $1,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on November 20, 2019 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required, provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92004) and ophthalmoscopy (92225) provided May 11, 2017.
You asked the Plan to pay for the vision services. You say that this claim is for medically necessary services. You did everything possible to have the information ready and file the claim on time yet it was out of your control. The Plan denied your request. The Plan says the diagnoses codes used are invalid for the date of service.
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 diagnoses codes H35.3124 and H35.3121 are invalid for the date of service. Based on this information, we decided that Medicare rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive eye exam (92004) and ophthalmoscopy (92225) provided May 11, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided by an OON dentist on September 12, 2019.
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you were not told that this dentist was different. You also say that you were never told that they were no longer in-network with your plan. The Plan denied your request. The Plan says the treating provider is a non-contracted provider. The Plan also says that no calls were made prior to this date of service to verify the treating provider's network status.
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 pay for the periodic oral evaluation and prophylaxis provided by an OON dentist on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these 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 has network providers
available who can provide 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 medical services provided to the enrollee by an out-of-network provider
on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on October 29, 2019. 
 
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 64772 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 64772 is transection or avulsion of other spinal nerve, extradural. 
 
We find that CPT code 64772 is not supported in the medical record. Specifically, the operative report does not contain documentation of transection or avulsion of a spinal nerve. 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 surgical services rendered on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray provided on January 8,
2020.
You asked the Plan to pay for the first intraoral periapical x-ray. You say that you have seen this provider for
over 20 years. You also say that you do not know any other dentist in the local area. The Plan denied your
request. The Plan says this 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, first intraoral periapical x-ray is not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 0005U) provided to the enrollee on May
10, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this is not a covered benefit.
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 0005U is "ONCOLOGY (PROSTATE) GENE
EXPRESSION PROFILE BY REAL-TIME RT-PCR OF 3 GENES (ERG, PCA3, AND SPDEF), URINE,
ALGORITHM REPORTED AS RISK SCORE."
We find that CPT code 0005U is not supported in the medical record. Specifically, this code is not covered or
is considered medically necessary by Medicare. Based on this information, we decided that Medicare rules for
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for lab
services (CPT 0005U) provided to the enrollee on May 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on September 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on November 13, 2019.
You asked the Plan to waive the copayment for an ambulance trip. You say that you only wanted them to pick you up from the floor. You say that you should not be held responsible for this copayment. 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for an ambulance trip. Since ambulance services were provided, the correct copayment has been applied. An ambulance trip falls 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 an ambulance trip provided on November 13, 2019.
We note your complaint about only wanting help off the floor. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit (96374)
provided February 7, 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 cost-sharing 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 $90
copayment for Emergency Care.
You have been asked to pay a $90 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 (96374) provided February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan and radiation therapy rendered on May 1, 2019.
You asked the Plan to waive the copayments for these services. You say that the charges are more than the original estimate. The Plan denied your request. The Plan says the copayments 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, and a $60 copayment for each Medicare-covered radiation therapy.
The file shows that the enrollee received a CT scan on May 1, 2019. The enrollee has been asked to pay a $100 copayment for these services. These services fall within the Medicare-covered radiological diagnostic service, not including x-rays benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.
The file shows that the enrollee received radiation therapy on May 1, 2019. The enrollee has been asked to pay a $60 copayment for these services. These services fall within the Medicare-covered radiation therapy benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan.
The total amount the enrollee has been asked to pay for these services is $160. 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 copayments for the computed tomography (CT) scan and radiation therapy rendered on May 1, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the upper extremity for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that a plain film of the arm is medically necessary prior to proceeding to an MRI.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee is noted to have a right forearm mass. The mass is noted to be painful and growing in size. The mass is apparently solid, as it feels similar to a lipoma, but lipomas are not usually painful or tender. It is unclear why the mass has not been previously evaluated. While it may be possible to obtain an US, CT or biopsy to further evaluate the mass, it is not unreasonable to obtain a MRI, instead of a CT or US, or prior to a biopsy or surgery. The documentation supports that the requested MRI is medically necessary and reasonable. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the upper extremity for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are requesting additional incontinence products for the enrollee. You say that the enrollee's secondary coverage approved one hundred and eighty incontinence products a month for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.