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

We decided that the Plan does not have to pay for genetic testing (CxBladder monitor) provided to the enrollee on November 9, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this cannot be approved.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing is not covered. The enrollee received non-covered testing on the date of service at issue in this case. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (CxBladder monitor) provided to the enrollee on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 11, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The services at issue were billed with POS 11 for an office setting, but the records show that the sample was taken in an SNF (POS 31). Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on January 13, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that the doctor didn't do anything so you should not be charged an office visit. The Plan denied your request. The Plan says you were charged
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 Physician Services, specialist office visit. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the Physician Services, specialist office visit 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 specialist office visit provided on January 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 29, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you felt that there was no reason for you to be transported to the hospital because you did not hit your head or break any skin when you fell. The Plan denied your request. The Plan says ambulance service without transport or paramedic intercept service is 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 January 29, 2021. 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 for the ambulance response and treatment with no transport (A0998) provided on January 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent for the enrollee.
You asked the Plan to pre-approve this drug. You say that the patient has trialed and failed several topical and oral treatments for his eczema. The Plan denied your request. The Plan says that this is not covered under 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 pre-approve Dupixent for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the dental services provided on January 29, 2021. We decided that the Plan does not have to pay for the dental services provided on July 27, 2020.
You asked the Plan to pay for the dental services. You say that you are covered for 1 preventive exam per year. You say that your dentist advised they were in network prior to your appointment. You also say that this should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that services performed out of network are not covered.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on December 25, 2019.

You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. 

In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. 

We find that CPT code 99284 is not supported in the medical record. Specifically, the emergency room progress note does not meet the complexity and severity of condition, physical examination and consultation of code 99284. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on December 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on March 5, 2021.

You asked the Plan to waive the copayment for the laboratory services. You say that you should not have a copayment for labs due to the medical necessity of the services. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Review of the file show that you received the laboratory services on March 5, 2021. You were asked to pay a $25 copayment for the laboratory services. Your 2021 EOC states that enrollees must pay a $25 copay for Medicare-covered lab services.

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 laboratory services provided on March 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided January 4, 2020 to January 6, 2020.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with N17.9 (Acute kidney failure, unspecified). 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 inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the enrollee presented to the facility for treatment of altered mental status. The documentation shows that the enrollee's creatinine ranged from 3.2 to 3.6, Glomerular filtration rate (GFR) values ranged from 12.6 to 14.5, and there was no mention of a fall in urinary output. While the enrollee indicated a baseline creatinine of 2, the physician noted that this was unverified and documented that the baseline was unknown in the progress notes. There was no documentation to support the enrollee had a rise in creatinine of 50% above baseline or a 25% reduction in GFR during the admission. The enrollee was scheduled to follow up with Nephrology to establish Chronic kidney disease (CKD) care after discharge. In this case, there was insufficient objective clinical evidence to validate the diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided January 4, 2020 to January 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for remote interrogation device evaluation (93294, 93296) provided February 3, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you did not go to the provider's office and should not have a copay for the services. You were at home and they provided services through the device. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 copayment for Medicare covered diagnostic radiology services. You have been asked to pay $50 ($35.19 + $14.81) copayment for the diagnostic services. The diagnostic
services fall 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 remote interrogation device evaluation (93294, 93296) provided February 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Sincalide 5MCG Injection (CPT code J2805) and Hepatobiliary system imaging test (CPT code 78227) provided on April 1, 2021.
You asked the Plan to waive the copayment for the services. You say that you should not have to pay the office's mistake as it was them who scheduled this appointment and should have cancelled it if the test was not needed or at least returned your calls advising the test was not needed so you could cancel the appointment yourself. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits. The Plan states your complaint regarding the timeliness of the communication between you and your physician's office has been forwarded to the Plan's Grievance Team for research and review, and you will receive a separate response from that team regarding your complaint.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received a Sincalide 5MCG Injection (CPT code J2805) and Hepatobiliary system imaging test (CPT code 78227) on April 1, 2021. You were asked to pay a $100 copayment for the Hepatobiliary system imaging test. Furthermore, you have been asked to pay 20% coinsurance of the allowed amount for prescription drugs. The allowed amount is $57.58. The total you owe is $11.52 ($57.58 x 20% = $11.52). Your total cost share responsibility is $111.52 ($100 + $11.52 = $111.52). Your 2021 EOC states that enrollees must pay 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs and a $100 copayment for Medicare-covered Nuclear Medicine at a freestanding provider. 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 Sincalide 5MCG Injection (CPT code J2805) and Hepatobiliary system imaging test (CPT code 78227) provided on April 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on January 11, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Guardant360 testing is only covered for certain 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 Guardant360 testing. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee has metastatic (cancer has spread) cystic carcinoma (rare form of cancer that begins in glandular tissues) right axillary (under arm). The enrollee was started on treatment based on her diagnosis and the genetic testing completed. The Medicare LCA criteria are not met for the Guardant 360 as tissue-based, comprehensive genomic profiling (CGP) is not infeasible and was accomplished at Foundation lab. The results were available to provider. The testing, therefore, does not meet LCA coverage criteria and appears to be duplicative and not medically necessary. 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 Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided February 27, 2021, through March 1, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were held at the medical facility against your will because there was no space at the mental health facility. 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 $345 copayment per day (per Medicare-covered stay), which includes day of admission and day of discharge for inpatient hospital care. You have been asked to pay a total of $690 ($345 copayment per day x 2 days = $690) for the inpatient hospital stay. This service 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 for the inpatient hospital stay provided February 27, 2021, through March 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound (76642) provided January 14, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you are appealing the charge $79.91. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $105 copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a freestanding facility. You have been asked to pay $79.91 copayment for the diagnostic service. Since the allowed amount of $79.91 is less than the copayment amount of $105, you are responsible for the lesser amount. The diagnostic service 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 the breast ultrasound (76642) provided January 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cystourethroscopy (52353) performed on April 16, 2021.

You asked the Plan to waive the copayment for a cystourethroscopy. You say that you do not feel the full copayment should be your responsibility because the service at issue was a continuation of a surgery in February 2021. The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $550 copayment for each visit for outpatient surgery services. 

You have been asked to pay a $550 copayment for a cystourethroscopy. A cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cystourethroscopy (52353) performed on April 16, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on February 10, 2021.

You asked the Plan to pay for the evaluation and management service. You say that you have been trying to get the provider to submit a correctly claim. You also say that this should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on June 30, 2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, these services were provided in the home setting (place of service 12). This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) received February 15, 2021.
You asked the Plan to pay for the resin-based composite. You say that the filling was necessary. The Plan denied your request. The Plan says fillings are limited to two (2) 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, the requested items or services are only covered under this benefit for two procedure codes per year. The Plan has submitted evidence that you received two fillings on February 1, 2021. Your benefit for fillings was exhausted for the year when you received this
service on February 15, 2021. Therefore, we decided that the Plan does not have to pay for the resin-based composite - one surface, posterior (D2391) received February 15, 2021.