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

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 29, 2021 by a Medicare opt out provider.    You asked the Plan to pay for the periodontal maintenance. You say that you were advised to opt out because you had absolutely no interaction with Medicare at all since your practice was started in 2007. You also say that had you been informed that it would have affected dental reimbursements for your dental patients you would have reconsidered the choice to opt out. The Plan denied your request. The Plan says the treating provider's status shows they have opted out of Original Medicare participation. The Plan also says that the treating provider opted out of Medicare effective November 17, 2016, to November 17, 2022.  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 rendered by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on March 29, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the foot care services routine foot care coded as 11055, 11721 and 99213  You asked the Plan to pay for the foot care services . You say that you just saw this provider and he decided you should come every 50 days. The Plan denied your request. The Plan says the requested service is not covered under the Plan benefits.  The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails.   Records do not show that any of these conditions are present. The enrollee does not have a qualifying diagnosis for the requested routine foot care. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the foot care services have not been met. Therefore, we decided that the Plan does not have to pay for the routine foot care coded as 11055, 11721 and 99213
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more for the first intraoral periapical x-ray (D0220) provided on September 16, 2021 by an out-of-network (OON) provider.    You asked the Plan to pay for the problem focused limited oral evaluation and to pay more for the first intraoral periapical x-ray. You say that you feel that these services should be covered by your insurance. The Plan denied your request. The Plan says the problem focused limited oral evaluation does not meet the frequency requirements of the Plan. The Plan also says that the charge for the first intraoral periapical x-ray exceeds the allowable amount for this procedure.  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, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on January 20, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. You are also responsible for the difference between the billed amount and allowed amount for covered dental services received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) or pay more for the first intraoral periapical x-ray (D0220) provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) visit provided on August 30, 2021.  You asked the Plan to waive the copayment for the PCP visit. You say that there was no office visit, only the annual wellness exam was performed. 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 $10 copayment for each primary care physician (PCP) visit.   The records indicate that during your wellness visit, you also addressed concerns for hypertension, hypothyroidism, and hyperlipidemia. These services go beyond the scope of the annual wellness visit criteria. Therefore, you have been asked to pay a $10 copayment for the PCP visit. The PCP visit 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 copayment for a primary care physician (PCP) visit provided on August 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) you had on October 21, 2021.  You asked the Plan to waive the copayment for the MRI. You say that you didn't know about this copayment and you think you would have paid less if you didn't have insurance. The Plan denied your request. The Plan says you were charged this copayment 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 $300 copayment for MRIs.   You have been asked to pay a $300 copayment for the MRI. 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 magnetic resonance imaging (MRI) you had on October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on  September 17, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service.  Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the out-of-network (OON) provider on September 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an electrocardiogram (ECG) monitor service provided on August 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an ECG monitor service. You say that the enrollees physician ordered this service. The Plan denied your request. The Plan says prior authorization is required for all non-participating providers and services were available in-network.   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 an electrocardiogram (ECG) monitor service provided on August 27, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the ambulance services (A0429 and A0425) provided on September 3, 2021.  You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says that the diagnosis code billed is not appropriate for the services rendered.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has stated that the claim was not billed with a diagnosis code which indicated the medical condition of the member was such that transportation by any other means is medically contraindicated. The Plan has not forwarded the claim to show what diagnosis code was billed. The Plan has not forwarded additional information to indicate why these services were denied. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the ambulance services (A0429 and A0425) provided on September 3, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the abdomen and pelvis provided on September 10, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you assumed the CT scan would be included in your ER 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 $225 copayment for advanced imaging services, including CT scans.   You have been asked to pay a $225 copayment for the CT scan. The CT scan 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 a computed tomography (CT) scan of the abdomen and pelvis provided on September 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from September 20, 2021, to September 27, 2021.  You asked the Plan to waive the copayment for inpatient hospital services. You say that you were directed by the primary care physician to go to the hospital and be admitted and to be processed through the emergency room. The Plan denied your request. The Plan says you were 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 $325 copayment per day for days 1 through 5 for in-network covered hospital care.     You have been asked to pay a total of $1,625 for five days of inpatient hospital services ($325 copayment x 5 days = $1,625). 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 inpatient hospital services rendered from September 20, 2021, to September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for 3 additional units of code 88313 (Special stain including interpretation and report) provided on May 27, 2021.  You asked the Plan to pay for 3 additional units of code 88313. You say that the medical records support the billing of the 3 additional units of code 88313. The Plan denied your request. The Plan says the medical records do not support the billing of the 3 additional units of code 88313.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 3 additional units of code 88313. Our reviewer says that the medical records do not support the billing of the 3 additional units of code 88313. Our physician reviewer found the enrollee received laboratory services on May 27, 2021. The provider billed 11 units of code 88313, the MUE value for this code is 8. The additional 3 units are in question. The limited documentation in the case file is insufficient to demonstrate that the additional 3 units of code 88313 were medically reasonable and necessary for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 additional units of code 88313 have not been met. Therefore, we decided that the Plan does not have to pay for 3 additional units of code 88313 (Special stain including interpretation and report) provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 15, 2021, through March 19, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.  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 per day, for days 1-5 and a $0 copayment per day for additional days, for inpatient hospital care.    You have been asked to pay $900 ($300 copayment x 3 days) for the inpatient hospital care provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 15, 2021, through March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on October 26, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that the ordering physician is an in-network physician and services did not need a prior authorization. The Plan denied your request. The Plan says the referring and participating providers are out-of-network, and no prior authorization was approved.   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 laboratory services provided on October 26, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic activities (97530) and the therapeutic exercises (97110) rendered by the out-of-network (OON) provider on June 3, 2021.  You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 therapeutic activities (97530) and the therapeutic exercises (97110) rendered by the out-of-network (OON) provider on June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology and physician services provided to the enrollee on October 1, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee had another primary insurer at the time of service. The Plan states that before they can process the claim, they need the primary insurance to provide an explanation of benefits showing they reviewed the claim. The Plan contracted the primary insurer and spoke to a representative who indicated they are having difficulty locating the enrollee in their database. The Plan states they contacted your office and were told by your staff that it can take 30 to 45 days to bill the Primary Insurance. The Plan states once the claim is submitted properly and the required explanation of benefits is received, the Plan will review as the secondary insurer.   The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has contacted the primary insurer and your office to try and coordinate the appropriate billing of this claim. As the secondary insurer, the Plan cannot be held responsible for these services until they are reviewed by the primary insurer.  Therefore, we decided that the Plan does not have to pay for radiology and physician services provided to the enrollee on October 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on October 5, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that this consultation was not necessary. The Plan denied your request. The Plan says this service is not covered.  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 problem focused limited oral evaluation (D0140) provided on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on September 13, 2021.  You asked the Plan to waive the copayment for the specialist telehealth visit. You say that you were unaware that there would be a charge for the follow-up phone call. 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 $50 copayment for specialist telehealth services.  You have been asked to pay a $50 copayment for the specialist telehealth visit. The specialist telehealth visit 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 copayment for a specialist telehealth visit provided on September 13, 2021.