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

We decided that the Plan does not have to pay for laboratory testing provided by provider on August 28, 2019.You asked the Plan to pay for lab testing. You say that these lab tests were not completed at an outpatient hospital, surgical facility, or during any inpatient confinement.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were performed during an inpatient confinement and therefore the Place of Service (POS) code billed is not correct.The Plan must follow Medicare rules. Medicare rules say that if an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off-campus outpatient hospital (POS code 19) or on-campus outpatient hospital (POS code 22) respectively. We looked at the file and Medicare rules. This testing was performed on a sample taken in an inpatient hospital setting, therefore the Place of Service (POS) code 81 -indicating an independent laboratory setting -is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab testing have not been met.Therefore, we decided that the Plan does not have to pay forlaboratory testing provided by provider on August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTrulicity.You asked the Plan to pre-approveTrulicity. You say that youwould like the Plan to reconsider their denial.The Plan denied your request. The Plan says Trulicity is not covered under your Medicare Part B benefit.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 pre-approveTrulicity.Benefits for Trulicitymay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CYP panel rendered to enrollee on October 16, 2019.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 testing is not covered.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 rules say that all CYP panels should be billed with 81479 and are non-covered.The test at issue in this appeal, a CYP panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Furthermore, the testing was not billed with the required 81479 code.Therefore, we decided that the Plan does not have to pay for the CYP panel rendered to enrollee on October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimitedoral evaluation (D0140) provided November 22, 2019.You asked the Plan to pay forthe dental services. You say that your healthcare plan is a PPO and you have never had a list of doctors or dentists that were in a specific network and you do not understand why this procedure was considered out of network.The Plan denied your request. The Plan says the requested 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, wedecided that the Plan does not have to pay forlimited oral evaluation (D0140) provided November 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on October 21, 2019.
You asked the Plan to pay for the eye refraction (92015). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says eye refractions, even in regards to cataract surgery, are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.
The services you asked the Plan to pay for are considered routine vision services or eyewear and are not covered by the Plan unless the eye refraction was performed during an annual routine eye exam. The file shows you received eye refraction services in preparation for cataract removal. The eye refraction was not performed during an annual routine eye exam. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forurgently needed services provided on September 15, 2019.You asked the Plan to waive the copayment forurgently needed services. You say that you feel that you should only owe a $5 copayment.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 withthe Plan clearly says that you must pay a $30 copayment for each visit in a contracted urgent care center or walk-in clinic for urgently needed services. You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services fallwithin the urgently needed 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 forurgently needed services provided on September 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the IVIG infusions provided from October 29, 2019 to October 30, 2019.
You asked the Plan to waive the coinsurance for the infusions. You say that you were not aware of the cost. The Plan denied your request. The Plan says that you received the applicable procedure and as such the copayment is due.
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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the infusions. The infusions fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the IVIG infusions provided from October 29, 2019 to October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to enrollee from June 1, 2019 to June 28, 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 the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment. We looked at the file and Medicare rules. The claims were not billed with a valid TOB code. 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 forthe home health services rendered to enrollee from June 1, 2019 to June 28, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ER visits provided from January 16, 2020 to January 26, 2020.You asked the Plan to waive the copayment for ER visits. You say that the ER visits were due to the plan's error.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 $90 copayment for emergency care. You received ER visits from January 16, 2020 to January 26, 2020 for a total of 3 visits. Therefore, you are responsible to pay a $90 copayment per each visit. The total amount you owe is: $90 (copayment) x 3 (ER visits) = $270.You have been asked to pay the total copayment amount of $270 for ER visits. ER visits fall 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 ER visits provided from January 16, 2020 to January 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnvarsus tablets at a lowercost (tier exception).You asked the Plan to pre-approveEnvarsus tablets at a lower cost (tier exception). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says tier exceptions only apply toPart D drugs.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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan's contract and Medicare rules. In this case, you are requesting a tier exception for Envarsus tablets. Medicare says that tier exceptions only apply to Part D drugs. Under Medicare rules, your request is not covered for a tier exception because Envarsus tablets are not covered under Medicare Part D. This drug is covered under your Medicare Part B (medical) benefit.Therefore, we decided that the Plan does not have to pre-approveEnvarsus tablets at a lower cost (tier exception).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a drug injection provided on November 5, 2019.
You asked the Plan to waive the coinsurance for a drug inject. You say that you disagree with the charges because your husband only paid $5 for the same injection. 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 Medicare Part B prescription drugs. You received a drug injection on November 5, 2019. The allowed amount is $1,156.80 and 20% of that is $231.36. You have been asked to pay the total coinsurance amount of $231.36 for a drug injection. A drug injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a drug injection provided on November 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe orthopedic services provided on September 18, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the documentation does not support the billed services. Code 27514 is more appropriate.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 27507 is Open treatment of femoral shaft fracture with plate/screws, with or without cerclage. 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 services provided. Our physician reviewer found that the enrollee suffered a distal femur fracture, rather than a mid-femur fracture (i.e. femoral shaft fracture). Therefore, the billing of CPT 27507 is not supported.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 services provided have not been met. Therefore, we decided that the Plan does not have to pay forthe orthopedic services provided on September 18, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the wrist (73220).You asked the Plan to pre-approve the MRI of the wrist. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage are not met.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 of the wrist. Our reviewer says that coverage criteria has not been met. Our physician reviewer found There is no clinical rationale for an MRI of the wrist. The patient has complaints of wrist pain with some neurologic symptoms. The patient had a MRI of the cervical spine, which did not show any significant findings related to the hand symptoms. Radiographs of the wrist were negative.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 of the wrist have not been met.Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the wrist (73220).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on November 12, 2019.
You asked the Plan to pay for the resin-based composite. You say that there is no detailed information for dental insurance on your Plan's website, and you do not know what the limit for fillings is. The Plan denied your request. The Plan says you exceeded the number of allowed fillings for the 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, restorations are limited to two procedures per calendar year. The record shows that you received fillings on October 25, 2019 and November 12, 2019 and your restorations benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on November 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora stress test provided by an in-network provider on January 13, 2020.You asked the Plan to waive the copayment fora stress test. You say that you do not know why you are being charged this amount.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 $75 copayment for outpatient diagnostic tests/advanced imaging service. You have been asked to pay a $75 copayment for a stress test. The correct copayment has been applied to the service that as provided. A stress test falls within the outpatient diagnostic tests/advanced imaging 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 fora stress test provided by an in-network provider on January 13, 2020.The Plan has determined that you are not being held responsible for the copayment amount of $22.23. Please contact the Plan about any further questions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on October 4, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you did not see the member. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 forlab work provided onOctober 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomplete upper denture (D5110).You asked the Plan to pre-approvethe complete upper denture. You say that your current set is painful to wear and chewing food is extremely difficulty. You've went several times to get them adjusted. This provider said you need a new upper denture as they cannot be fixed.The Plan denied your request. The Plan says the request exceeds the benefit frequency limit.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. This service is allowed once every 5 years. The records show that this service was provided June21, 2019.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-approvecomplete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on December 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that these services were provided in a skilled nursing facility. You say thatyou would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract withthe 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 forskilled nursing services provided on December 12, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for filling (D2330) crown-porcelain/ceramic
substrate (D2740) provided December 5, 2019.
You asked the Plan to waive the copayment for the dental services. You say that the dentist destroyed your
teeth and you were mistreated by the provider and the office staff. They have charged you for services that you
did not receive. The Plan denied your request. The Plan says this claim was processed correctly per the 2019
EOC.
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 50%
coinsurance on non-Medicare covered comprehensive dental services.
You have been asked to pay $390 for the dental services. The services fall within the Dental 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 filling (D2330) crown-porcelain/ceramic
substrate (D2740) provided December 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lower partial dentures (D5821).
You asked the Plan to pre-approve the lower partial dentures. You say that you do not understand why you are getting denied if you have never had dentures. This is new to you and you are missing teeth on the sides. The Plan denied your request. The Plan says the requested 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 pre-approve the lower partial dentures (D5821).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says that
the plan requires you to receive care from providers who are part of your primary care physician's (PCP)
specialty network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers. The contract with
the Plan also says that the plan requires the enrollee to receive care from providers who are part of the
enrollee's primary care physician's (PCP) specialty network.
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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services