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

We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 4,
2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you didn't have the radiology
tests. You say that you only had a regular office visit. The Plan denied your request. The Plan says the
copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 per
day, per in-network provider, for diagnostic procedures and tests.
You have been asked to pay a $10 copayment for the ultrasound. The ultrasound falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The records show that the ultrasound
was performed. 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 ultrasound provided on February 4,
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) cleaning (D1110) bitewing x-rays (D0274) provided February 19, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that dental services must be rendered by a participating provider. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract specifically says on page 83 supplemental dental services must be received from a participating provider in order to be covered by the plan. 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 periodic oral exam (D0120) cleaning (D1110) bitewing x-rays (D0274) provided February 19, 2020 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) and deluxe frame (V2025) provided on February 8, 2020 by an out-of-network provider.
You asked the Plan to pay for the eyewear. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says progressive lenses and deluxe frames are not covered under your plan.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. According to your plan benefits for post cataract vision hardware, you must receive services from a participating provider, or have an approved authorization for services with any out-of-network provider. A prior authorization was not in place prior to the February 8, 2020 services. The plan made a one-time exception and paid the Medicare-covered vision hardware you received on February 8, 2020. Your vision benefits will pay for one pair of basic frames and lenses each calendar year. You also requested reimbursement for vision hardware that is not covered by Medicare: progressive lenses and deluxe frames. Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) and deluxe frame (V2025) provided on February 8, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes J2545 and Q0513 provided on January 1, 2020.
You asked the Plan to pay for CPT codes J2545 and Q0513. 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 providers must report services correctly.
We looked at the file and Medicare rules. Medicare says the NDC code must be correct. In this case, the claim
was billed with the incorrect NDC and CPT codes J2545 and Q0513 are not payable as billed. The Plan will
accept a corrected claim for reconsideration. Based on this information, we decided that Medicare rules for
coverage of CPT codes J2545 and Q0513 have not been met. Therefore, we decided that the Plan does not have
to pay for CPT codes J2545 and Q0513 provided on January 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home health visit provided on January 27, 2020. 
 
You asked the Plan to pay for the home health visit. The Plan denied your request. The Plan says nonemergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 home health visit provided on January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from February 1, 2019 to March 1, 2019.You asked the Plan to waive the copayment for the SNF stay. You say that you were not aware that the copayment would be $172 per day. 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 $0 copayment per day, days 1-20 and a $172 per day, days 21-100 for each in-network SNF stay. You have been asked to pay a $2,580 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) 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 SNF stay provided from February 1, 2019 to March 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on February 26, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you feel that the colonoscopy should be considered a screening and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for outpatient surgery provided in an outpatient hospital facility.  
 
The medical records show that you received a diagnostic colonoscopy due to a positive Cologuard test on February 26, 2020. Therefore, you are responsible to pay the $400 copayment.  
 
You have been asked to pay a $400 copayment for a colonoscopy. A colonoscopy 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 colonoscopy provided on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on December 18, 2019.
You asked the Plan to waive the copayment for the endoscopy. You say that this wasn't surgery, it was a test that had to be done. You say that this was not billed correctly. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulatory surgical center services. You have been asked to pay a $250 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a surgical procedure. 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 endoscopy provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 23, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says that 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 hospital outpatient clinic visit provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2019.
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 must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection by nucleic acid testing provided on February 3, 2020.
You asked the Plan to pay for laboratory test. You say that this testing was medically necessary as ordered by the enrollee's treating provider. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not a Medicare benefit for the diagnosis listed.
The Plan must follow Medicare rules. Medicare rules say that procedure code 87798 is only covered by Medicare when billed with certain, specific diagnosis codes. We looked at the file and Medicare rules. The diagnosis code billed on this claim is not among those for which procedure code 87798 is covered. Based on this information, we decided that Medicare rules for coverage of laboratory test have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection by nucleic acid testing provided on February 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from July 7, 2018 through July 14, 2018 and the ambulance transport provided on December 12, 2019.
You asked the Plan to waive the copayment for the inpatient stay and ambulance transport. You submitted bills for review. You say that you were not informed that you had to pay and be reimbursed. The Plan denied your request. The Plan says the copayments 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). The enrollee's contract with the Plan clearly says that enrollees must pay $195 per day, days 1-9 and $0 per day, days 10-90 for each inpatient stay and a $295 copayment for each Medicare-covered, one-way trip via ground ambulance. The enrollee has been asked to pay a total of $1,660 for the inpatient stay and ambulance transport. The inpatient stay falls within the "Inpatient hospital care" benefit category. The ambulance transport falls within the "Ambulance services" benefit category. This means that 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 copayment for the inpatient stay provided from July 7, 2018 through July 14, 2018 and the ambulance transport provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CaSR gene testing.
You asked the Plan to pre-approve the requested services. You say that CaSR testing would rule in a benign familial disorder, and simplify subsequent management. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 requested services. Our physician reviewer found that the enrollee is noted to have primary hyperparathyroidism, exhibited by mild elevations in both his serum calcium levels and his parathyroid hormone level. The enrollee is apparently asymptomatic and is not receiving any specific treatment for the condition. While it would be interesting, it is not necessary to determine if the enrollee has familial hypercalcemia in order to monitor or treat him. As such, the requested test is not shown to be medically necessary or reasonable. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve CaSR gene testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transthoracic echocardiography.
You asked the Plan to pre-approve transthoracic echocardiography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that transthoracic echocardiography 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 pre-approve transthoracic echocardiography. Our reviewer says that the documentation does not support that the requested echocardiography services are medically reasonable or necessary. Our physician reviewer found you were seen for a physical. "TE: reviewed" was noted but no context or results of such testing was documented. You reported intermittent episodes of dizziness lasting seconds for the past 2 weeks. No other cardiac symptoms were reported such as swelling, chest pain, or shortness of breath. Vitals were normal. Labs were reviewed and not significantly abnormal.
Examination findings were normal, including normal heart findings. No plans for testing were noted. The provided documentation is insufficient and not recent enough to help justify a transthoracic echocardiography at this time. There was no noted signs or symptoms or history of a cardiac diagnosis which requires this test. Therefore, this request for a transthoracic echocardiography will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transthoracic echocardiography have not been met. Therefore, we decided that the Plan does not have to pre-approve transthoracic echocardiography.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment the office visit provided on January 13, 2020.You asked the Plan to waive the copayment the office visit. You say that you could not see your primary care doctor on this date of service, so you saw the nurse practitioner. You say you should have a $0 copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay $0 copayment for provider and professional services at an in-network PCP's office. The Plan says you must pay a $25 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for the office visit. The record shows that the billing provider is a primary care office. Therefore, we decided that the Plan has to waive the copayment the office visit provided on January 13, 2020.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the manipulation of knee joint under anesthesia on March 5, 2020.
You asked the Plan to waive the copayment for the manipulation of knee joint under anesthesia. You say that you disagree with the charges because you had to pay for physical therapy for 4 weeks but the knee would still not bend. 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 $200 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $200 copayment for the manipulation of knee joint under anesthesia. The manipulation of knee joint under anesthesia 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 the manipulation of knee joint under anesthesia on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crown - porcelain fused to base metal teeth 6 and 11 (D2751) and crown full cast base metal tooth 5 (D2971).
You asked the Plan to pre-approve the dental services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says that did not meet the criteria for restorative services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that this enrollee meets the criteria for coverage for the requested service. Our physician reviewer found a review of the enrollee's dental record and radiographs indicate that a fixed bridge replacing missing teeth #'s 7, 8 and 9 was lost. Teeth #'s 5, 6, 10 and 11 were used as abutment crowns for the fixed bridge. The enrollee was left with missing anterior pontics and missing crowns on teeth #'s 5, 6, 10 and 11. The only way to restore missing crowns is to replace them with new crowns. These would serve as abutments for the maxillary partial denture which has been approved. The request for new crowns for teeth #5, #6 and #11 meets the criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to pre-approve crown - porcelain fused to base metal teeth 6 and 11 (D2751) and crown full cast base metal tooth 5 (D2971).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on February 13, 2020 by an out of network (OON) provider.You asked the Plan to pay for radiology services. You say that you 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 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 radiology services provided on February 13, 2020 by an out of network (OON) provider.