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

 We decided that the Plan does not have to waive the copayment for the biopsy procedure you had at an outpatient hospital facility on June 29, 2021.  You asked the Plan to waive the copayment for the biopsy procedure. You say that you do not think it is fair that you are charged this copayment because teh clinic is owned by the hospital. 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 $250 copayment for surgery services in an outpatient hospital facility.   You have been asked to pay a $250 copayment for the biopsy procedure. Records show that the facility where you had these services bills as an outpatient hospital facility. This means that the biopsy procedure falls within the surgery services in an outpatient 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 the biopsy procedure you had at an outpatient hospital facility on June 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy provided on May 26, 2021, through June 14, 2021.  You asked the Plan to pay for the physical therapy. You say that the services should be covered. The Plan denied your request. The Plan says there is insufficient documentation to determine medical necessity.  The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the physical therapy provided on May 26, 2021, through June 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ECG provided on June 22, 2021.  You asked the Plan to waive the copayment for an ECG. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for non-radiological diagnostic services.   You have been asked to pay a $20 copayment for an ECG. An ECG 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 an ECG provided on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for complete breast ultrasound (76641) provided March 29, 2021.  You asked the Plan to pay for the diagnostic services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services and confirm Medicare coverage has been met.  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, the CPT Code Manual definition of code 76641 is a ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete.  We find that CPT code 76641 is not supported in the medical record. Specifically, the medical records submitted do not include a procedure report detailing an ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for complete breast ultrasound (76641) provided March 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on March 31, 2021.  You asked the Plan to pay for the evaluation and management service. You say that the enrollee's hospice election was revoked on March 1, 2021. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on March 1, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on March 31, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from March 25, 2021, to March 28, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you were advised you could not bring your own medications to the hospital. You say that you are on a fixed income. You also say that your portion of the bill should be reduced. The Plan denied your request. The Plan says the medication you received on the dates of service in this case are considered self-administered drugs. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says that self-administered drugs are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from March 25, 2021, to March 28, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services (procedure code G0483) provided to the enrollee on March 24, 2020.  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 Healthcare Common Procedure Coding System (HCPCS) code G0483 (1 Unit) remains not supported.  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 procedure code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 pay for drug testing services (procedure code G0483) provided to the enrollee on March 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for two resin-based composites (D2331 and D2332) provided by an out-of-network provider on July 29, 2021.  You asked the Plan to pay for a resin-based composite. You say that your Medicare card says that dental is included. The Plan denied your request. The Plan says the first filling was covered at 50%. The Plan says that after the first filling, the rules for fillings have been exhausted.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a resin-based composite once per calendar year.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a resin-based composite have been processed correctly. The first filling was covered at 50% coinsurance ($93 x 50% = $46.50). The second filling was not covered ($155) due to the benefit already being exhausted. We decided that the Plan has correctly processed the two resin-based composite (D2331 and D2332) provided by an out-of-network provider on July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided on May 4, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the inpatient services. You say that the services should be covered. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services obtained by an out-of-network provider.  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 inpatient services provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency department visit provided on July 30, 2021.  You asked the Plan to waive the copayment for an emergency department visit. You say that you do not feel you should be responsible for the copay because you were following doctor's orders. 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 $90 copay for each emergency care visit.   You have been asked to pay $65.92, which is less than the $90 copay for an emergency department visit. An emergency department visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency department visit provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a cardiovascular stress test (78452, A9502, 93017, J2785) rendered on July 15, 2021.  You asked the Plan to waive the copayment for a cardiovascular stress test. You say that the copayment of $250 is a big amount of a social security check, even on monthly payments, when one has to live on it with no other income. 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 $250 copayment for nuclear medicine services in an outpatient.  You have been asked to pay a $250 copayment for nuclear medicine services in an outpatient hospital for a cardiovascular stress test. Cardiovascular stress tests fall 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 cardiovascular stress test (78452, A9502, 93017, J2785) rendered on July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an inpatient admission provided from August 20, 2020, through August 23, 2020.  You asked the Plan to pay for an inpatient admission. The Plan denied your request. The Plan says the medical record does not document that the physician medical group was contacted for prior authorization for out-of-network services.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from August 20, 2020, through August 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (82570, 83970, 83036) provided March 24, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed codes are not separately payable.  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 82570, 83970, & 83036 are not supported in the medical record. Specifically, the services billed are separate professional components to lab services. These services are not separately payable. 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 for lab services (82570, 83970, 83036) provided March 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a computed tomography (CT) scan provided on July 23, 2021.  You asked the Plan to waive the coinsurance for a CT scan. You say that you feel the service should be covered since you were already charged the $10 copay for an urgent care visit. 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 20% coinsurance up to $75 per day for diagnostic radiology services.   You have been asked to pay $75 for a CT scan. CT scans fall 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 coinsurance for a computed tomography (CT) scan provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal evaluation (D0180) and maintenance (D4910), provided on March 8, 2021.  You asked the Plan to pay for the periodontal evaluation and maintenance. You say that the services should be covered. The Plan denied your request. The Plan says periodontics are 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 periodontal evaluation (D0180) and maintenance (D4910), provided on March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on August 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the hospital care. You say that you were admitted for open heart triple bypass surgery. This procedure was authorized by the Plan. The Plan is claiming the physician is out of network. Until receiving the denial letter you were not aware of this. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. The diagnosis on this claim is not covered because it is excluded by the Plan.  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 subsequent hospital care (99232) provided on August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an x-ray of the hip with pelvis (code 73503) provided by on May 6, 2021.  You asked the Plan to waive the deductible for an x-ray. You say that based on your plan, you should only be charged $15. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  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 certain services.   The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to certain services. This cost sharing is a contractual obligation that had not been met at the time an x-ray was received on May 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an x-ray of the hip with pelvis (code 73503) provided by on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the provisional crown (D2799) provided on June 23, 2021.  You asked the Plan to pay for the provisional crown. You say that this service was necessary and there was no other option at that time. You also cannot afford this expense. The Plan denied your request. The Plan says provisional crowns are not covered by your dental 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 for the provisional crown (D2799) provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pharmacogenomic panel testing provided on June 8, 2021.  You asked the Plan to pay for panel testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this multi-gene panel testing should be billed with single procedure code 81479.  The Plan must follow Medicare rules. Medicare rules say that multi-gene panels are described with procedure code 81479.   We looked at the file and Medicare rules. This multi-gene panel should be billed with single procedure code 81479. Based on this information, we decided that Medicare rules for coverage of panel testing have not been met. Therefore, we decided that the Plan does not have to pay for pharmacogenomic panel testing provided on June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 29, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. 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 must 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 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 out of network services provided to the enrollee on June 29, 2021.