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

We decided that the Plan does not have to reduce the copayment for the Echocardiography, transthoracic, realtime
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral
Doppler echocardiography, and with color flow Doppler echocardiography (93306) provided September 10,
2021.

You asked the Plan to reduce the copayment for the echocardiography. You say that you were seen in an
imaging facility, not a hospital, and therefore the copayment should only be $50. 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 $175
copayment for each Medicare-covered outpatient diagnostic procedure and test in an outpatient facility.

You have been asked to pay a $175 copayment for the echocardiography. The echocardiography falls within
the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The Plan called the
facility that rendered the services and verified that the facility was correctly categorized as an outpatient
facility. 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 reduce the copayment for the Echocardiography, transthoracic, real-time
with image documentation (2D), includes M-mode recording, when performed, complete, with spectral
Doppler echocardiography, and with color flow Doppler echocardiography (93306) provided September 10,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the dental services provided from August 26, 2020, to September 27, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the dental services. You say that you feel you should be reimbursed for these services because you were referred to the OON provider by your oral surgeon. The Plan denied your request. The Plan says your contract only provides coverage for dental services when they are performed by a participating general dentist. The Plan also says that there is no benefit for dental services performed by OON providers.  

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the dental services provided from August 26, 2020, to September 27, 2021 by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for the visual field examination (92083) provided on August 5, 2021.  

You asked the Plan to pay for the visual field examination. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 92082 and 92083.  

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 92083 is a column II code to column I code 92082. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the visual field examination (92083) provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an office visit provided on September 10, 2021.  You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges because you should not owe anything for a wellness visit. 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. Your contract with the Plan says that there is a $750 deductible which applies to out-of-network physician/practitioner services, including doctor's office visits.   You had an office visit with an out-of-network provider on September 10, 2021. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had only paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $254.39.  The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on September 10, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on September 10, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the breast imaging services provided on July 26, 2021.  

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that an inappropriate modifier was billed.  

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  

We looked at the file and the rules. The file shows that you received services by a contract provider. Billing issues from a participating provider are not your responsibility. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the breast imaging services provided on July 26, 2021.   

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Leuprolide Acetate injection you received on April 16, 2021.
You asked the Plan to waive the coinsurance for the Leuprolide Acetate injection. You say that you received this same injection in 2019 and 2020 and did not have to pay a copayment. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B and chemotherapy drugs. You have been asked to pay 20% coinsurance for the Leuprolide Acetate injection. The Leuprolide Acetate injection falls within the Medicare Part B and chemotherapy drugs benefit category. This coinsurance applies
regardless of what you may have paid in the past. 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 the Leuprolide Acetate injection you received on April 16, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy provided on September 1, 2021.
You asked the Plan to pay for the colonoscopy. You say that you were sent home right after the service, and it should not have been billed under outpatient. 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 $475 copayment for each Medicare- covered outpatient hospital facility visit.
You have been asked to pay a $475 copayment the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the colonoscopy was provided and 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 pay for the colonoscopy provided on September 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services provided September
16, 2021, to September 25, 2021.

You asked the Plan to waive the coinsurance for the dialysis services. You say that the Plan used to cover
dialysis better in 2017. You cannot afford the cost. The Plan denied your request. The Plan says the
coinsurance 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 20%
coinsurance per treatment for outpatient dialysis treatments.

You have been asked to pay $422.36 ($2,111.74 x 20% coinsurance = $422.36) for the dialysis services. the
dialysis services fall within the Services to treat kidney disease 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 the dialysis services provided September 16, 2021, to
September 25, 2021.

Your complaint about the Plan having different coverage for dialysis services in a previous year 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 17, 2021.  You asked the Plan to pay for the services provided. You say that there is no agreement which indicates the codes are included in the dialysis rate. The Plan denied your request. The Plan says the lab tests are the responsibility of the dialysis center.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable.     We looked at the file and the rules. The records provided show the labs at issue were provided as part of the enrollee's ESRD treatment. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulatory surgery provided on October 26, 2021.  

You asked the Plan to waive the copayment for the ambulatory surgery. You say that you are a senior on a fixed income and cannot afford the copayment. The Plan denied your request. The Plan says the proper 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 same-day outpatient surgery in a freestanding Ambulatory Surgical Center.     

You have been asked to pay a $350 copayment for the ambulatory surgery. Ambulatory surgery falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulatory surgery provided on October 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided on July 16, 2020.

You asked the Plan to pay for the services provided. You say that you were open with limited staff hours. The Plan denied your request. The Plan says the claim was filed beyond the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services provided was not filed until July 22, 2021. 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 the skilled nursing facility services provided on July 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction (routine eye exam) provided on October 12, 2021.  You asked the Plan to pay for eye refraction. You say that you were never told that there would be a separate charge for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because an eye refraction is only covered when performed by a Plan routine vision care network provider.  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. The Plan covers these services when obtained from a Plan routine vision care network provider.  We looked at the file and the Plan's rules. This provider is not part of the Plan's routine vision care network. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (routine eye exam) provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction you received on October 5, 2021.  

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered benefit.  

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. The Plan covers these services when provided by a network vision care provider.  

We looked at the file and the Plan's rules. The records in this case do not show that the refraction in this case was provided by a network vision care provider. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you received on October 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance supplies provided on August 14, 2021.

You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says this is not a covered 
benefit.

The Plan must follow Medicare rules. Medicare rules say that payment for ambulance supplies is included in 
the fee schedule payment. 

We looked at the file and Medicare rules. The requested ambulance supplies provided to you during transport 
are not separately payable. Payment for these items and services is included in the payment for the ambulance 
transportation. 

Based on this information, we decided that Medicare rules for coverage of the supplies have not been met.
Therefore, we decided that the Plan does not have to pay for the ambulance supplies provided on August 14, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 30, 2021.  

You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  

The file shows that CPT code 70450 was billed with code 70496. We find that CPT code 70450 may be eligible for payment when billed with this code pair. The claim information does now show that the code at issue was not billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on May 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 9, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.

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 services provided by an out-of-network provider on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for complete series x-ray (D0210) provided on September 21, 2021.  You asked the Plan to pay for the x-ray. You say that you were not informed of the pricing of additional services. You also say that you feel you should not be charged. The Plan denied your request. The Plan says complete series x-ray is not listed as a covered service.  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 complete series x-ray is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for complete series x-ray (D0210) provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the specialist telehealth services provided on July 19, 2021, and August 20, 2021  You asked the Plan to waive the copayments for the specialist telehealth services. You say that the phone calls only lasted a couple minutes to refill your prescription. The Plan denied your request. The Plan says the copayment was appropriately 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 $45 copayment for each Medicare-covered specialist visit. The copayment for July 19, 2021, was $45 and the copayment for August 20, 2021, was $45. The total amount for both copayments is $90 ($45 copayment + $45 copayment).  You have been asked to pay a $90 copayment for both specialist telehealth services. The specialist telehealth service falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist telehealth services provided on July 19, 2021, and August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the telehealth services you received on August 19, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not covered out-of-network.  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 out-of-network virtual care is not covered.  Review of the file shows that you were provided out-of-network telehealth/virtual care services on August 19, 2021. You have been asked to pay the full cost of these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. Out-of-network virtual care is not covered under your plan  Therefore, we decided that the Plan does not have to pay for the telehealth services you received on August 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for eye surgery performed on September 14, 2020.  

You asked the Plan to waive the copayment for the eye surgery. You say that you do not believe that you should be charged the extra copayment. 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 $200 copayment for each outpatient surgery at an ambulatory surgical center.   

You have been asked to pay a $200 copayment for the eye surgery. The eye surgery 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 eye surgery performed on September 14, 2020.