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

We decided that the Plan does not have to waive the co payment for the surgical procedure you had in your urologist's office.

You asked the Plan to waive the co payment for the urology services. You say that you were told that there would be no co payment for a surgical procedure in the office.The Plan denied your request. The Plan says you were charged this co payment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 co payment for medical care or surgery services furnished in a specialist's office. 

You have been asked to pay a $35 co payment for the urology services. The urology services fall within the medical care or surgery services furnished in a specialist's office 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 co payment for the surgical procedure you had in your urologist's office.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (G0416) provided April 17, 2020.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says the number of units billed exceeds the allowed amount.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code G0416 is 1. You billed 6 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forlab services (G0416) provided April 17, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Town  on August 7, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.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 August 7, 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 forthe ambulance services provided by THE Town on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora radiographic imaging procedure (D0274) performed on July 24, 2020.You asked the Plan to pay fora radiographic imaging procedure. You say that you were told the provider was an in-network provider.The Plan denied your request. The Plan says rules for payment have not been met.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For thatreason, 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.You have not elected to purchase an optional supplemental benefit that includes the requested items or services.Therefore, we decided that the Plan does not have to pay fora radiographic imaging procedure (D0274) performed on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says these services were not emergent, urgent or approved in advance.Medicare rules say that planscan 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 forthe medical services provided on July 7, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 4, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that the ultrasound was not completed and 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 $0 copayment for procedures provided in a physician's office and a $125 copayment when provided at any other location. The medical records show that you received an ultrasound on August 4, 2020. Therefore, you are responsible to pay the $125 copayment. You have been asked to pay a $125 copayment for an ultrasound. An ultrasound 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 ultrasound provided on August 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on February 27, 2020 and billed under code 97110.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria are not met.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 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 this service. Our reviewer says that the records provided do not support the services billed. Our physician reviewer found the documentation does not support the CPT code 97110 described as "a therapeutic procedure, on one or more areas, each lasting 15 minutes, to develop strength, endurance, range of motion and flexibility" was performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on February 27, 2020 and billed under code 97110
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forfacet joint injections (64634) provided on November 18, 2019.You asked the Plan to pay forfacet joint injections. You say that this was billed correctly.The Plan denied your request. The Plan says that this code is not documented.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 64634 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure).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 facet joint injections. Our reviewers says that the two units of this code are supported. Our physician reviewer found the procedure report documents medial branch nerves corresponding to the right C3/C4, C4/C5, C5/C6 facet levels injected. Therefore, this code can be confirmed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have been met.Therefore, we decided that the Plan has to pay forfacet joint injections (64634) provided on November 18, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe mammogram (77067). You say that you would like reconsideration because you were not told that this facility was not in-network.The Plan denied your request. The Plan says services must be provided in-network to be eligible for payment.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 forthe medical services provided on August 17, 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 copayment for the visual field exam provided on June 11,
2020.
You asked the Plan to waive the copayment for the visual field exam. You say that you are being double billed
for the same test which should be covered in full. 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 a $50
copayment for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye,
including treatment for age-related macular degeneration.
You have been asked to pay $41.22, which is less than the standard $50 copayment for the visual field exam.
The visual field exam falls within the "Vision 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 the visual field exam provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on September 1, 2020.
You asked the Plan to reimburse you for the eyeglasses. You say that the Plan provides $650.00 to buy eyewear and you do not agree with the amount you received. The Plan denied your request. The Plan says the reimbursement was correctly paid per the Plan benefits.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an out-of-network provider with a 20 % coinsurance. We looked at the file and the Plan's rules. The file shows that you purchased the eyeglasses from an out-of-network provider and that the claim process correctly based on the eyewear benefit. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on September 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe azithromycin provided in an outpatient setting on July 16, 2020.You asked the Plan to pay forthe self-administered drug. You say that this claim was a result of a sexual assault case that happened on your apartment patio. You say that you were advised to go to this location for the exam, questioning, medications, and follow up. You also say that the services should be covered.The Plan denied your request. The Plan says the drug that you received in the outpatient setting is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says that the self-administered drug is not covered under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe azithromycin provided in an outpatient setting on July 16, 2020.Benefits for the self-administered drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services coded 93306 provided.

You asked the Plan to pay for the echocardiography services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.

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 93306 is echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography.

We find that CPT code 93306 is not supported in the medical record. Specifically, services are not paid by any provider or supplier for services furnished to the enrollee for surgery. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors. The enrollee received the services in preparation for / following surgery at the facility. Payment for this service would be included in the facility PPS payment. Based on this information, we decided that Medicare rules for coverage of the echocardiography services have not been met.Therefore, we decided that the Plan does not have to pay for the echocardiography services coded 93306 provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
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 medical services provided on June 7, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable oxygen concentrator purchased on June 21, 2020.You asked the Plan to pay forthe portable oxygen concentrator. You say that you would like reconsideration because this will lower the Plan's and your personal, healthcare costs.The Plan denied your request. The Plan says Medicare does not cover purchased oxygen equipment.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for oxygen equipment that is purchased.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Specifically, the record indicates that you purchased the portable oxygen equipment. This is not a Medicare covered benefit.Therefore, we decided that the Plan does not have to pay forthe portable oxygen concentrator purchased on June 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning services provided August 6, 2020, from
an out-of-network (OON) provider.
You asked the Plan to pay for the dental cleaning services. You say that you were under the impression that
services you received were rendered by a network provider. The Plan denied your request. The Plan says
coverage is not available for procedures performed 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. The Plan covers the dental
cleaning services when the services are rendered by a network provider.
We looked at the file and Medicare rules. The file indicates that the services you received you performed by an
OON provider. Based on this information, we decided that the Plan's rules for coverage of the dental cleaning
services have not been met. Therefore, we decided that the Plan does not have to pay for the dental cleaning
services provided August 6, 2020, from an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 5, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 forthe medical services provided on February 5, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) report and interpretation rendered on May 15, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 93010 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of an EKG interpretation and report. 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 electrocardiogram (EKG) report and interpretation rendered on May 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from May 24, 2020, through May 28,2020.You asked the Plan to waive the copayment forthe inpatient stay. You say that you are not able to pay this bill.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 $195 each Medicare-covered day for days 1-6 for each inpatient hospitalization.You have been asked to pay a $780 copayment for the inpatient stay. ($195/day x 4 days = $780). The inpatient stay falls within the "Inpatient hospital 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 forthe inpatient stay provided from May 24, 2020, through May 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy (S9328) provided on March 16, 2020, through June 19, 2020.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration because this is not durable medical equipment and was not delivered to the member's home.The Plan denied your request. The Plan says the billed service is not covered by Original Medicare.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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy (S9328) provided on March 16, 2020, through June 19, 2020.