Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe arthrocentesis provided on September 17, 2020.You asked thePlan to waive the copayment forthe arthrocentesis. You say that you were in a clinic setting that is no longer a fully functioning hospital. You say that this visit and injection do not fall into the category of outpatient surgery.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 clearlysays that you must pay a $200 copayment for in-network, Medicare-covered outpatient hospital surgery services.You have been asked to pay a $200 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including servicesprovided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical service that was billed by the hospital. 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 forthe arthrocentesis provided on September 17, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forfluoroscopic guidance for needle placement (77002) provided on March 11, 2020.You asked the Plan to pay forfluoroscopic guidance for needle placement. You say that this code is supported in the records.The Plan denied your request. The Plan says there is not a primary procedure for this code.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, we have confirmed that code 77002has a Column One/Column Two relationship with code 64483and cannot be paid as billed. This code cannot be paid as a separate line item.CPT 64483 includes fluoroscopic guidance.Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forfluoroscopic guidance for needle placement (77002) provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and preventive procedure (D1999) provided on August 18, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and preventive procedure. You say that you feel these services should be covered because the problems happened shortly before you saw the new dentist. The Plan denied your request. The Plan says the comprehensive oral evaluation exceeds the frequency limitation in your benefit plan. The Plan also says that unspecified preventive procedure is not a covered benefit under your dental plan.
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 unspecified preventive procedure is not among those covered under this benefit. The contract also clearly states that comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on September 27, 2019, and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and preventive procedure (D1999) provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical placement of mini implant and abutment supported porcelain/ceramic crown provided on August 5, 2020.You asked the Plan to pay forthe surgical placement of mini implant and abutment supported crown. You say that you checked your dental coverage and saw that crowns were covered, and proceeded with the work. Youalso say that you do not understand why the crown is not covered.The Plan denied your request. The Plan says implants, abutments, and implant-related services are not benefits of the dental plan.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 forthe surgical placement of mini implant and abutment supported porcelain/ceramic crown provided on August 5, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on August 25, 2020. You asked the Plan to waive the copayment for an outpatient surgery. You say that you do not agree with this
copayment. The Plan denied your request. The Plan says the correct copayment has been applied. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for outpatient surgery/in-network/hospital facility. You have been asked to pay a $350 copayment for an outpatient surgery. The correct copayment has been
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/in-network/hospital facility 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 an outpatient surgery provided by a participating provider on August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor at the in-network rate.
You asked the Plan to pre-approve these services. You say that in-network benefits should be allowed. The Plan denied your request. The Plan says the services are available from in-network providers at the in-network rate.
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% of the Medicare-allowed amount for each out-of-network Medicare-covered chiropractic visit.
You are requesting a referral to an out-of-network chiropractor. If you choose to see this provider, you will be asked to pay 50% of the Medicare-allowed amount for these services. These services fall within the out-of-network Medicare-covered chiropractic 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. The Plan has network providers available who can provide services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor at the in-network rate.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Emergency Medical Service on November 7, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are 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 November 7, 2019. 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 forthe ambulance services provided by THE Emergency Medical Service on November 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided from February 27, 2020, to April 15, 2020.You asked the Plan to pay forthese services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.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 has network providers available who can provide 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 forout of network physician services provided from February 27, 2020, to April 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder/arm orthosis provided to the enrollee.

You asked the Plan to pay for the orthosis. You say that this item was medically necessary.The Plan denied your request. The Plan says that your request is not a covered benefit because records show that the evaluation did not take place at a qualifying originating site.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non covered visit are likewise non covered.Therefore, we decided that the Plan does not have to pay for the shoulder/arm orthosis provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forout of network physician services provided to the enrollee on June 8, 2020.You asked the Plan to pay forthis service. You say that this office visit should be covered by the Plan.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 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 forout of network physician services provided to the enrollee on June 8, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says there is no need for a fixed height bed.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 bed. Our reviewer says that the requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The head of the bed does not need to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. The request for a semi-electric hospital bed is 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 bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forprofessional services provided in the Republic of Nicaragua from August 2, 2019, to January 4, 2020.You asked the Plan to pay forforeign country services. You say that you do not agree with the amount that the Plan has reimbursed you for these claims.The Plan denied your request. The Plan says the denial of additional reimbursement for these requests is correct, because the Plan has reimbursed you up tothe allowable amount for these charges and you are responsible for a $50 copayment.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for services furnished outside of the United States and its territories, except in the limited circumstances described in the previous section. The Plan has a supplemental benefit for worldwide coverage that goes beyond Medicare coverage. For that reason, the Plan's rules apply to this case. The Plan covers emergency care services worldwide up to the Medicare allowable rate. You must pay $50 copayment for emergency care.You requested a total reimbursement amount of $2,189.13. For date of service August 2, 2019,you requested a reimbursement of $800 and the Plan reimbursed you up to the allowed amount of $267.12. For date of service September 9, 2019, you requested a reimbursement amount of $800 and the Plan reimbursed you up to the allowed amount of $545.15. For date of service November 25, 2019, you requested a reimbursement amount of $30and while the Plan approved this full amount, it was applied to your copayment because this amount is less than the $50 emergency care copayment. Therefore, the Plan fully reimbursed you for the requested charges except for $817.73, resulting in a reimbursement amount of $1,371.40.We looked at the file, the Plan's rules, and Medicare rules. Based on this information, we decided that the Plan does not have to make additional payment for these services.Therefore, we decided that the Plan does not have to pay forprofessional services provided in the Republic of Nicaragua from August 2, 2019, to January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent observation care, for the evaluation and management of a patient (99226) provided on February 8, 2020.You asked the Plan to pay forsubsequent observation care. You say that please review the documentation provided in this appeal. The services and procedures performed warrant separate payment of each CPT code originally submitted.The Plan denied your request. The Plan says the benefit for this service is included in the payment/allowance for another service that has already been adjudicated.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, we have confirmed that code subsequent observation care has a bundled relationship with code 99233and cannot be paid as billed. This code cannot be paid as a separate line item. Subsequent Hospital Care codes are "per diem" services, they may be reported only once per day by the same physician or physicians of the same specialty from the same group practice, whether the problems seen during the encounters are related or not. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forsubsequent observation care, for the evaluation and management of a patient (99226) provided on February 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the claim was processed correctly.

The Plan follows Medicare rules. The rules say that claims for services furnished on, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for office visit services provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services rendered on July 10, 2020.You asked the Plan to waive the copayment forthese services. You say that this was a yearly office visit.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, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit for laboratory tests. Review of the file shows that you received laboratory services on July 10, 2020. These services fall outside of the scope of an annual wellness exam. You have been asked to pay a $20 copayment for these services. These services fall within the laboratory tests 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 forthe laboratory services rendered on July 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core buildup, including any pins when required (D2950) provided on June 9, 2020.You asked the Plan to pay forthe core buildup. You say that this was a routine procedure done after youhad a root canal.The Plan denied your request. The Plan says this service is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe core buildup, including any pins when required (D2950) provided on June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on July 1, 2020.
You asked the Plan to waive the copayment for the lab services. You say that you believe you only had a catheter change and no bloodwork on this date. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for these labs ($7.09) 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 $10 copayment for diagnostic lab services. You have been asked to pay a $10 copayment for the lab services. The medical records from this date of service clearly indicate that you did receive 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 lab services you had on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora cardiovascular risk panel (81405, 81406, 81408) performed June 15, 2020.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says this is not a covered service.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 codes 81405, 81406, & 81408 are not supported in the medical record. Specifically, the service at issue is non-covered by Medicare. 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 fora cardiovascular risk panel (81405, 81406, 81408) performedJune 15, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on April 14, 2020.You asked the Plan to pay forhome infusion therapy. You say that the enrollee was referred for this service by an in-network provider.The Plan denied your request. The Plan says this was not billed with a valid code.The Plan must followMedicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not haveto pay forhome infusion therapy (S9328) provided on April 14, 2020.