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

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on March 8, 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 office visit (99213) rendered by the out-of-network (OON) provider on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory testing provided on August 30, 2021.  You asked the Plan to pay for the lab testing. You say that this should be paid with the billed diagnosis codes. The Plan denied your request. The Plan says medical records were not submitted to support the necessity of this testing.  The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient information to confirm that Medicare coverage criteria have been met.  In this case, only the order was submitted. The Plan documented requests for the office visit that led to the requested testing, but the provider indicated that no such record was available. As such, the provider has not provided sufficient information to support that coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on August 30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on
September 6, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be
covered.
The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $90
copayment for Emergency care.
You have been asked to pay a $90 copayment for an emergency room visit. 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 room visit provided on September 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 2, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.
We looked at the file and Medicare rules. The file does not contain documentation of an established
relationship between the enrollee and the ordering provider. Without a record showing that this provider is
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services rendered on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99214) rendered on
September 16, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you went to your annual physical
and had just that. You also say that you were not treated for any other related issues. 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 enrollees must pay a
$0 copayment for an annual physical. The Plan contract also says that if you receive services that address a
medical condition during the same office visit, additional cost-share may apply. The Plan contract also says
that enrollees must pay a $10 copayment for each covered visit in an outpatient location with your primary care
provider.
You have been asked to pay a $10 copayment for an office visit. The record shows that the annual visit also
addresses more than just the annual physical. 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 office
visit (99214) rendered on September 16, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Tempus Gene Panel provided on February 20, 2021.

You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this claim has not been billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Tempus Gene Panel. Our reviewer says that the review indicates that the enrollee has pancreatic cancer. The Tempus xT assay is a custom oncology testing panel consisting of 648 genes with single nucleotide variants, indels and translocations measured by hybrid capture next-generation sequencing (NGS). Our physician reviewer found the review has determined that the items/services at issue in this case medically reasonable and necessary to determine the appropriate treatment strategy. 

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 Tempus Gene Panel have been met. Therefore, we decided that the Plan has to pay for the Tempus Gene Panel provided on February 20, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hospital inpatient stay, and emergency
room visit provided from May 23, 2021, to May 28, 2021.
You asked the Plan to waive the copayment for the hospital inpatient stay, and emergency room visit. You say
that the services should be covered, and you do not feel like you should have to pay for these services. The Plan
denied your request. The Plan says the cost-sharing applied correctly based on 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 $90
copayment for emergency care and a $390 copayment per day for days 1-5 of Inpatient hospital care.
You have been asked to pay a $90 copayment for an emergency room visit and a $1,950 copayment for five
days of an inpatient hospital stay. 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 hospital inpatient
stay, and emergency room visit provided from May 23, 2021, to May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab testing provided on August 17, 2021.  You asked the Plan to pay for the lab testing. The Plan denied your request. The Plan says screening tests are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab testing provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 and the
service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on August 13,
2021.
You asked the Plan to pay for the CT and the service(s) provided between 10:00 PM and 8:00 AM at 24-hour
facility. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan
says the services billed are not 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. In this case, we have confirmed that code 70450
is a column II code to column I code 70496. 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. We find that CPT
code 99053 is not supported in the medical record. Specifically, this code has a status indicator of "B". A status
indicator of B means that payment for covered services is always bundled into payment for other services not
specified. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) coded
70450 and the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided
on August 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transportation of the portable x-ray (R0070) provided on July 8, 2021.  You asked the Plan to pay for the transportation of the portable x-ray. 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 R0070 and R0075.  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 R0070 is a column II code to column I code R0075. 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 transportation of the portable x-ray (R0070) provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing provided on August 17, 2021.  You asked the Plan to pay for the SelectMDx testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of this testing.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SelectMDx testing have not been met. Specifically, per the diagnostics exchange which applies to labs located in California, the SelectMDx test is not covered. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional resin-based composite provided on September 16, 2021.

You asked the Plan to pay for the additional resin-based composite. You say that you were told fillings were covered, and you do not agree with the denial of payment. The Plan denied your request. The Plan says your benefits for this service 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of two amalgam or composite fillings per calendar year. The Plan paid for one resin-based composite provided on March 5, 2021, and September 16, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the additional resin-based composite provided on September 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87798) provided June 5, 2020.  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 this service was for screening purposes and is non-covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (87798) provided June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 19, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed based on the
medical documentation. The Plan denied your request. The Plan says prior authorization was not obtained for
these services rendered by an OON 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 office visit (99214) provided on May 19, 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 coinsurance for a talimogene laherparepvec injection provided on September 15, 2021.  

You asked the Plan to waive the coinsurance for the injection. You say that you had the same procedure done in August and the copayment was cheaper. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for Part B drugs, including chemotherapy drugs.   

You have been asked to pay $5,633.28, which is 20% of the allowed amount for the injection ($28,166.40 allowed amount x 20% coinsurance = $5,633.28). Please note that the injection provided in August was a smaller dose, resulting in a lower charge and coinsurance. The injection falls within the Medicare Part B Prescription Drugs 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 talimogene laherparepvec injection provided on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an out-of-network provider on July 7, 2021, to July 13, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you would like the Plan to pay for this. 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 $375 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care/in-network.    You have been asked to pay a $375 copayment per day for days 1-5. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,875 ($375 x 5 days = $1,875). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 inpatient hospital stay provided by an out-of-network provider on July 7, 2021, to July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and
supplies (K0553), provided on June 27, 2021.
You asked the Plan to pay for the CGM and supplies. You say that the items were medically necessary. The
Plan denied your request. The Plan says documentation submitted did not sufficiently support the billed supply
code; nor did documentation indicate the provider discussed the need for the billed supply code
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a relevant medical records which support medical necessity for the supplies
provided in this case. The records submitted to not indicate medical necessity for this item nor do they show
the treating physician ordered or discussed the purchased DME with the member. The record shows that the
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that
the Plan does not have to pay for the continuous glucose monitor (CGM) (K0554) and supplies (K0553),
provided on June 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93010) provided on September 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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. In this case, we have confirmed that code 93010
is a column II code to column I code 62270. 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 services (93010) provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle brace (L1971) and heel stabilizer (L3170),
provided on April 27, 2021.
You asked the Plan to pay for the ankle brace and heel stabilizer. You say that the item is medically necessary.
The Plan denied your request. The Plan says documentation submitted did not sufficiently support the billed
supply code; nor did documentation indicate the
provider discussed the need for the billed supply code
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The records submitted do not indicate medical necessity or that the treating physician order or
discussed the need for the purchased DME with the patient. The record shows that the Plan made several
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not
have to pay for the ankle brace (L1971) and heel stabilizer (L3170), provided on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for emergency room services and outpatient
surgery services provided from June 30, 2021, to July 3, 2021.
You asked the Plan to waive the copayments for emergency room services and outpatient surgery services. You
say that you would like to be reimbursed because you were overcharged. The Plan denied your request. The
Plan says the proper copayment was applied for the emergency care services. There was an error in the surgery
services claim with has been fixed and the proper copayment has now 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 $100
copayment for emergency services in an emergency room and a $250 copayment for each outpatient hospital
visit. The total copayment for these services was $350 ($100 copayment + $250 copayment).
You have been asked to pay a $100 copayment for emergency room services and a $250 copayment for
outpatient surgery services. The emergency room services falls within the Emergency care benefit category.
The outpatient surgery services falls within the Outpatient surgery, including services provided at
hospital 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
copayments for emergency room services and outpatient surgery services provided from June 30, 2021, to July
3, 2021.