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

We decided that the Plan does not have to pay for the home infusion therapy services provided to the enrollee from October 8, 2019 to October 15, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided to the enrollee from October 8, 2019 to October 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that the provider chose to send the test to your lab to device a treatment plan that they felt was best for the enrollee. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 April 24, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on October 8, 2019.
You asked the Plan to pay for the bitewing x-rays. You say that when you spoke with a plan representative, you were told that only one x-ray was allowed per year, not two. You also say that when you contacted the provider about the charge, they told you that your plan must have made a change in the 2019 benefit year that their office did not receive. The Plan denied your request. The Plan says this service exceeds the frequency limitation in 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, bitewings are limited to one set per plan year. The record shows that you received bitewing x-rays on March 12, 2019 and your bitewings benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe outpatient clinic visit provided on May 20, 2019.You asked the Plan to waive the coinsurance forthe outpatient clinic visit. You say that you were informed the doctor was in-network. You say that you don't think you are responsible for the charges.The Plan denied your request. The Plan says the coinsurance 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 30% coinsurance for each Medicare-covered,out-of-network specialist visit. Covered services include medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location. You have been asked to pay $31.21, which is 30% of the allowed amount for the outpatient clinic visit. The allowed amount is $104.04 (30% x $104.04= $31.21). The outpatient clinic 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 coinsurance forthe outpatient clinic visit provided on May 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forTrain of Four monitoring (95937) provided on October 31, 2019.You asked the Plan to pay forthe Train of Four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support that CPT code 95937 was performed.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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in the record. Specifically, the record indicates that CPT code 95937is being used to represent Train of Four monitoring. This does not meet the CMS guidelines of CPT code 95937. Based on this information, we decided that Medicare rules for coverage of the Train of Four monitoring have not been met.Therefore, we decidedthat the Plan does not have to pay forTrain of Four monitoring (95937) provided on October 31, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the emergency room and inpatient hospital services provided to enrollee from August 2, 2019 to August 22, 2019.You asked the Plan to waive the copays for the services provided. You say that you cannot afford the charges.The Plan denied your request. The Plan says the claims processed according to the planbenefits.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 file shows that the enrollee received an emergency room visit on August 2, 2019. He was charged a $90 copay for the services provided. The services fall within the emergency are benefit category. The enrollee received inpatient services from August 15, 2019, to August 22, 2019, totaling 5 days. A $185 copay was applied to each day,totaling $925. The services fall within the inpatient hospital care benefit category. The enrollee has been asked to pay the correct amount based on the contract with the Plan. 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 copays for the emergency room and inpatient hospital services provided to enrollee from August 2, 2019 to August 22, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe echocardiogram provided on December 12, 2019.You asked the Plan to waive the copayment forthe echocardiogram. You say that you were told there was no copayment. You say your appointment was changed to the day before the office visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 copayment for each Original Medicare covered diagnostic test or procedure, such as heart catheterizations and sleep studies. (This copayment may not apply if you visit a PCP or specialist on the same date of service that the test or procedure was performed, and your plan has an office visit copay for that visit). You have been asked to pay a $10 copayment for the echocardiogram. The echocardiogram 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 forthe echocardiogram provided on December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the orthosis. You say that this was medically necessary. The Plan denied your request. The Plan says that the billed supply code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that a spinal orthosis is covered for the above indications. 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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The clinical Progress Notes in the case file indicate Reasons for Appointment of follow-up and evaluation of a variety of issues. There was no complaint of back pain. There was no documented examination of the back. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for the orthosis. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis (L0650) provided to the enrollee on November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe urinary tract x-ray coded 74420 provided on July 26, 2019.You asked the Plan to pay forthe urinary tract x-ray. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are a duplicate.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 74420 is urography, retrograde, with or without KUB.We find that CPT code 74420 is not supported in the medical record. Specifically, this service is an exact duplicate claim/service already processed by the plan. Based on this information, we decided that Medicare rules for coverage of the urinary tract x-ray have not been met.Therefore, we decided that the Plan does not have to pay forthe urinary tract x-ray coded 74420 provided on July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 8 extractions and inhalation of nitrous oxide/analgesia provided on November 13, 2019 and December 4, 2019.You asked the Plan to pay for the extractions and nitrous oxide/analgesia. You say that a Plan representative said that codes D7140 and D7210 were covered at 100%, with no frequency disclosed.The Plan denied your request. The Plan says your benefits for extractions had been satisfied and the frequency limitations had been exceeded. The Plan also says that inhalation of nitrous oxide/analgesia is not a covered benefit. The Plan also says that the plan representative informed you that oral surgery had a frequency limitation of 2 procedures per year.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, extractions are limited to two procedures per calendar year. The record shows that you received extractions on November 8, 2019 and November 13, 2019 and your extractions benefit was then exhausted. The contract also says that anesthesia is covered as needed with covered procedures. Your extractions benefit was exhausted on November 13, 2019, and therefore, inhalation of nitrous oxide/analgesia provided on December 4, 2019 is not a covered benefit.Therefore, we decided that the Plan does not have to pay for the 8 extractions and inhalation of nitrous oxide/analgesia provided on November 13, 2019 and December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forDME provided on November 8, 2019 and December 8, 2019.You asked the Plan to waive the coinsurance forDME. You say that you disagree with the increase in 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 20% coinsurance for DME and related supplies. You received DME on November 8, 2019 and December 8, 2019. The allowed amount per each is $153.78 and 20% of that is $30.75. Therefore, the total amount you owe is: $30.75 (coinsurance) x 2 (DME) = $61.50.You have been asked to pay the total coinsurance amount of $61.50 for DME. DME falls within the 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 coinsurance forDME provided on November 8, 2019 and December 8, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) services rendered to you on April 24, 2019.You asked the Plan to waive the copayment forthese services. You say that you were attacked in the hospital and the hospital didn't have a qualified surgeon on hand.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 $90 copayment for in-network emergency room services. Review of the file shows that you received ER services on April 24, 2019. You have been asked to pay a $90 copayment for these services. These services fall within the in-network emergency room 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 forthe emergency room (ER) services rendered to you on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 18, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you disagree with the charges just because it was out of the time-frame. 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 $30 copayment for each specialist visit. You had a specialist visit on December 18, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on December 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveresin-based composite for teeth #7, 8, 9, 10 for the enrollee.You asked the Plan to pre-approvethe dental services. You say that this is medically necessary.The Plan denied your request. The Plan says this 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 pre-approveresin-based composite for teeth #7, 8, 9, 10 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on July 3, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a drug test provided on July 3, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71045) provided on August 9, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.
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 71045 is supported in the record. Specifically, the medical record and claim information indicate that this was a separate procedure rendered by a different provider. This claim has been billed with the appropriate modifier to indicate that this was a separate procedure. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have been met. Therefore, we decided that the Plan has to pay for a chest x-ray (71045) provided on August 9, 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 to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the hospital outpatient clinic visit provided on October 30, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the services in question were provided by a network provider on October 30, 2019. The case file we received is largely incomplete and missing required documentation. A majority of the documentation with this case file was for different dates of service in question. We requested this documentation on two separate occasions without response from the health plan. Therefore, we decided that the Plan has to hold you harmless for the hospital outpatient clinic visit provided on October 30, 2019 minus any cost share requirement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120), the prophylaxis (D1110), andthe complete series of periapical x-rays (D0210) provided on October 14, 2019 by an out of network dentist.You asked the Plan to reimburse you forthe dental services. You say that the Annual Notice of Changes (ANOC) states that up to $300 will bereimbursed for any dental services. You say that you had no idea about the DenteMax dentist because you never had to worry about that before. You also say that you should be reimbursed for the full amount because nowhere does it say anything about the DenteMax fees.The Plan denied your request. The Plan says the provider in this case does not participate with DenteMax. The Plan says that you were reimbursed the total maximum allowed amount of $146. The Plan also says that the claim processed correctly.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 and the dental services are listed as covered, the Plan will only pay up to the maximum allowable for services that are received out of network. You are responsible for the remaining amount.Therefore, we decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120), the prophylaxis (D1110), and the complete series of periapical x-rays (D0210) provided on October 14, 2019 by an out of network dentist.