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

We decided that the Plan does not have to waive the copayments for the Doppler echocardiography and the duplex scan you had on October 9, 2020.
You asked the Plan to waive the copayments for the Doppler echocardiography and the duplex scan. You say that you are questioning this bill because you do not know if these tests were necessary. The Plan denied your request. The Plan says you were charged these copayments 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 $155 for each radiological diagnostic service. You have been asked to pay a $155 for the Doppler echocardiography and a $155 copayment for the duplex scan. These tests within the each 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 copayments for the Doppler echocardiography and the duplex scan you had on October 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (ECG) you had on October 5, 2020.
You asked the Plan to waive the copayment for the ECG. You say that you did not have an ECG. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that the medical records from this date of service confirm that an ECG was performed.
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 diagnostic procedures and tests. You have been asked to pay a $10 copayment for the ECG. The ECG falls within the diagnostic procedures and tests benefit category. The medical records from the provider of service show that you had a 12-lead ECG on that date that demonstrated sinus rhythm and a heart rate of 78. 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 electrocardiogram (ECG) you had on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a podiatrist on October 20, 2020.
You asked the Plan to waive the copayment for the podiatry visit. You say that this visit was for toenail cutting, so there should be no copayment. 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 $15 copayment for podiatry visits. You have been asked to pay a $15 copayment for the podiatry visit. Your Evidence of Coverage specifically
states that this copayment applies to routine footcare for patients with diabetes. 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 office visit you had with a podiatrist on October 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had at an outpatient hospital facility on February 18, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for diagnostic radiology services (except ultrasounds). You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had at an outpatient hospital facility on February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
May 17, 2021, through May 18, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you were sick and needed to go to observation and the doctor recommended you stay overnight. The Plan denied your request. The Plan says an inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that you presented to the emergency department with dizziness. The workup was negative for a stroke or other acute condition. You were diagnosed with benign positional vertigo and were treated with meclizine and were recommended outpatient vestibular therapy. Based on the clinical notes, you would not have been predicted to require hospital services that would likely cross two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 17, 2021, through
May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392 x2) received January 28, 2021.
You asked the Plan to pay for the resin-based composites. You say that there is no reason why some of this should not be reimbursed. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392 x2) received January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on March 18, 2021.
You asked the Plan to waive the copayment for the EKG. You say that this was your annual check up and you have never had to pay separate for an EKG. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowable amount for the EKG ($14.80) is less than your copayment obligation, you are responsible for the full 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 $35 copayment for each EKG following the Welcome to Medicare visit. You have been asked to pay a $35 copayment for the EKG. 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 electrocardiogram (EKG) you had on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an ophthalmologist on February 19, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you already had to have a cataract evaluation on January 18, 2021, so you don't think you should have to pay a copayment for the second evaluation you had. The Plan denied your request. The Plan says the office visit on February 19, 2021 was for an evaluation of your left eye (in addition to a follow-up on your right eye). You had cataract surgery on your right eye, so you received services at this visit unrelated to the surgery you had. As a result, a copayment can apply to this service as the cost of this visit is not included in the cost for the surgery itself.
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 $45
copayment for visits with a specialist. You have been asked to pay a $45 copayment for the office visit. Medicare rules say that if you have a visit with your surgeon after surgery for something unrelated to the surgery itself, that follow-up visit is a separate service. In this case, your cataract surgery was on your right eye, but during your February 19, 2021 visit, the surgeon also evaluated your left eye. Since this evaluation is unrelated to the cataract surgery you had, a separate copayment can be charged. 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 office visit you had with an ophthalmologist on February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urology office visit you had on February 8, 2021.
You asked the Plan to waive the copayment for the urology visit. You say that there should be no copayment for prostate screening exams. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that while there is no copayment for an annual PSA test, you were treated and monitored for an existing medical condition during the visit, which is why a copayment applies.
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 $35 copayment for specialist visits. You have been asked to pay a $35 copayment for the urology visit. The records show that on this date of service, you not only received a prostate screening, but your complaint of weak urine stream was also reviewed
and you were prescribed a new medication for this condition. Since you received services beyond the prostate screening, that is why a copayment applies. The urology visit falls within the specialist 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 the urology office visit you had on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out of network (OON) provider on December 17, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out of network (OON) provider on December 17, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on September 27, 2020, and the hospital clinic visits with a specialist you had on September 28, 2020, and October 19, 2020.
You asked the Plan to waive the copayment for the ER visit and the specialist visits. You say that you received a box of samples from the Plan that contained eye drops. You said that you had an allergic reaction to the eye drops The Plan denied your request. The Plan says you were charged these copayments 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 emergency room visits and a $25 copayment for services rendered by a specialist in an outpatient hospital setting.
You have been asked to pay a $90 copayment for the ER visit and a $25 copayment for each of the specialist visits. These copayments apply regardless of the reason for the visits. 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 emergency room (ER) visit you had on September 27, 2020, and the hospital clinic visits with a specialist you had on September 28, 2020, and October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services (49587) provided January 6, 2021.
You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider at issue is not eligible for payment for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (49587) provided January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services represented by codes 12052x3, 12032x3, and 11102x3 provided on October 13, 2020.
You asked the Plan to pay for codes 12052x3, 12032x3, and 11102x3. 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 as billed.
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 12052 is 1. You billed 3 units of this code, exceeding the MUE. The MUE for CPT code 12032 is 1. You billed 3 units of this code, exceeding the MUE. The MUE for CPT code 11102 is 1. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of codes 12052x3, 12032x3, and 11102x3 have not been met. Therefore, we decided that the Plan does not have to pay for the physician services represented by codes 12052x3, 12032x3, and 11102x3 provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2021.
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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal are being requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation (92004), eye refraction (92015), and the ophthalmic biometry by ultrasound echography (76519) rendered by the out of network (OON) provider on September 1, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 ophthalmological medical examination and evaluation (92004), eye refraction (92015), and the ophthalmic biometry by ultrasound echography (76519) rendered by the out of network (OON) provider on September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided on March 9, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (81479) provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0482) provided December 10, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 80307, & G0482 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 for lab services (80307, G0482) provided December 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulance transport (A0425, A0429) provided December 28, 2020.
You asked the Plan to pay for the ambulance transport. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 A0425, & A0429 is not supported in the medical record. Specifically, the services were not billed with a valid provider type. Based on this information, we decided that Medicare rules for coverage of the ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for an ambulance transport (A0425, A0429) provided December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on December 23, 2020.
You asked the Plan to pay for the assistant surgeon services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a Registered Nurse First Assistant (RNFA) is not an eligible assistant to surgery per Medicare guidelines.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on December 23, 2020.