Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture (D0380) and pulp vitality tests (D0460) provided on August 31, 2020.
You asked the Plan to pay for the cone beam CT image capture and pulp vitality tests. You say that you told the provider that you only wanted services for tooth #33. You also say that you should not be held responsible for these services because they were not for tooth #33. The Plan denied your request. The Plan says these services are not covered under your plan. The Plan also says that you did not make any contacts to the Plan in regard to your cost share or provider questions for these 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. 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 cone beam CT image capture (D0380) and pulp vitality tests (D0460) provided on August 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are
not medically stable for transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that you presented to the hospital with sharp abdominal pain. Per the pulmonology report, you
had acute respiratory failure with hypoxia due to congestive heart failure. The plan is for abdominal wall
debridement once your respiratory issues are improved. Currently, you are not medically stable for transfer to
LTACH. You are receiving appropriate care at the present acute care hospital. There are no services available
at the LTACH that you require that are not available at the health care setting being offered by the health plan.
Therefore, the requested LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiologic examination, hand (73130) provided December 7, 2020
You asked the Plan to waive the copayment for the x-ray services. You say that this x-ray was performed in your primary provider's office and the copay should be $15. The Plan denied your request. The Plan says the claim was processed and the correct copayment was 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 $100 copayment for basic radiological services in an outpatient hospital. You have been asked to pay $75.20 for the x-ray services. Since the Medicare allowable amount was less than the $100 copay amount you are responsible for the lesser amount. The x-ray 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 radiologic examination, hand (73130) provided December 7, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ophthalmic ultrasound, diagnostic, corneal pachymetry (76514) scanning computerized ophthalmic diagnostic imaging (92134), ophthalmological services, medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92014) and ophthalmological services, medical examination and evaluation with initiation of diagnostic and treatment program (92004) provided August 25, 2020 to October 19, 2020
You asked the Plan to waive the coinsurance for the outpatient, diagnostic and vision services. You say that you had paid $1,495 when arriving at the clinic, an additional $111.39 to the eye clinic and $105.41 to the surgery center. You were told by a representative that you should get some sort of reimbursement. The Plan denied your request. The Plan says the claims were processed and the correct cost shares were 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 for each covered x-ray in a provider's office, 20% coinsurance for each covered surgery or observation room service in an outpatient hospital and $45 for each Medicare covered exam to treat an eye condition. You have been asked to pay $248.32 ($56.46 + $86.45 + $105.41) for the outpatient diagnostic and vision services. The outpatient diagnostic and vision services fall within the Outpatient diagnostic tests and therapeutic services and supplies, Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers and Vision 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 coinsurance for ophthalmic ultrasound, diagnostic, corneal pachymetry (76514) scanning computerized ophthalmic diagnostic imaging (92134), ophthalmological services, medical examination and evaluation, with initiation or continuation of diagnostic and treatment program (92012) and ophthalmological services, medical examination and evaluation with initiation of diagnostic and treatment program (92004) provided August 25, 2020 to October 19, 2020
Your complaint about being reimbursed about your payments made towards these services is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for acupuncture services provided from October 14, 2020, to November 9, 2020.
You asked the Plan to pay for the acupuncture services. You say that this service is a covered benefit. The Plan denied your request. The Plan says that Medicare does not cover acupuncture.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. For services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. The Plan covers acupuncture for chronic pain. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acupuncture services have been met. Therefore, we decided that the Plan has to pay for acupuncture services provided from October 14, 2020, to November 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a Laparoscopy, surgical, repair of paraesophageal hernia, includes
fundoplasty, when performed; without implantation of mesh (43281).
You asked the Plan to pre-approve a Laparoscopy, surgical, repair of paraesophageal hernia, includes
fundoplasty, when performed; without implantation of mesh (43281). You say that the requested Laparoscopy,
surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
(43281) is medically necessary. The Plan denied your request. The Plan says that the requested Laparoscopy,
surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
(43281) is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 a Laparoscopy, surgical, repair of
paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh (43281). Our
reviewer says that the requested Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty,
when performed; without implantation of mesh (43281) is medically necessary. Our physician reviewer found
the enrollee is with symptomatic large Type III paraesophageal hernia with part of her stomach herniated into
the chest. The enrollee is symptomatic with GERD and dysphagia refractory to medical management which has
worsened over the past 5 years. This enrollee has symptomatic GERD and a large type 3 PEH with herniation
of a portion of the stomach into the chest. Hiatal hernia repair with fundoplasty is a standard treatment and is
medically necessary and appropriate for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty,
when performed; without implantation of mesh (43281) have been met. Therefore, we decided that the Plan has
to pre-approve a Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when
performed; without implantation of mesh (43281).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MTHFR gene analysis provided on September 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the MTHFR gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the MTHFR gene analysis provided on September 30, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 28, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that the service you normally use was unavailable. 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on November 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram services provided on August 5, 2020.
You asked the Plan to pay for the services provided. You say that you were told if you paid in cash, a reimbursement would be given. The Plan denied your request. The Plan says an itemized bill was not submitted.
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 looked at the file and the rules. In this case, a claim, including a valid CPT code, was not submitted. There are no billing documents from the provider that indicate what services were provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the mammogram services provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on September 20, 2020.
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 procedure code 99233 is not covered.
The Plan must follow Medicare rules. The rules say that both Initial Hospital Care and Subsequent Hospital
Care codes are "per diem" services and may be reported only once per day by the same physician or physicians
of the same specialty from the same group practice.
We looked at the file and Medicare rules. Billed procedure code 99223 is not covered because the Plan
previously paid for another evaluation and management code for the same date of service. Therefore, we
decided that the Plan does not have to pay for the initial hospital care rendered on September 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95822) and somatosensory testing (95938) provided on August 12, 2020.
You asked the Plan to pay for an electroencephalogram and somatosensory testing. You say that POS 15 is correct for these services. The Plan denied your request. The Plan says these services were not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. We looked at the file and Medicare rules. The services at issue were billed with the Mobile Unit POS code 15, but the records show that these services were provided by a mobile unit servicing an entity for which another POS code already exists. Based on this information, we decided that Medicare rules for coverage of an electroencephalogram and somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95822) and somatosensory testing (95938) provided on August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve molecular pathology services (level 6) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there is not enough medical evidence to show that this testing helps the doctor make
better decisions about cancer treatment.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the CARIS testing requested includes markers that exceed the need to manage the enrollee's condition.
The elements of the coverage rule are not satisfied.
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 have not been met. Therefore, we decided that the Plan does not
have to pre-approve molecular pathology services (level 6) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on November 18, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you feel that this was a colonoscopy screening and you should not be responsible for 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you received a colonoscopy on November 18, 2020, due to diarrhea. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $300 copayment. You have been asked to pay a $300 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 November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, arthrocentesis, injection, and radiologic exam provided on October 8, 2020 by an out of network provider.
You asked the Plan to pay for the office visit, arthrocentesis, injection, and radiologic exam. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 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 office visit, arthrocentesis, injection, and radiologic exam provided on October 8, 2020 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological comprehensive medical examination and initiation of diagnostic and treatment program (92004) received September 3, 2020.
You asked the Plan to waive the copayment for the new patient complete exam of visual system. You say that you should pay $0 for the eye exam. The Plan denied your request. The Plan says the service received was a medical or diagnostic, not routine, eye exam, therefore the correct copayment applied to the claim.
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 Vision care. You have been asked to pay a $45 copayment for this service. The new patient complete exam of visual system falls within the Vision care benefit category. The requested service was medical or diagnostic in nature. 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 ophthalmological comprehensive medical examination and initiation of diagnostic and treatment program (92004) received September 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1852) provided October 3, 2020.
You asked the Plan to pay for the knee orthosis. You say that the item was medically necessary. The Plan denied your request. The Plan says the documentation submitted is missing required information.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the proof of delivery did not include an itemize order form or invoice to indicate the specific supplies; therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1852) provided October 3, 2020.