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

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 13, 2021.  

You asked the Plan to pay for ambulance response and treatment, no transport. You say that your blood pressure was over 300 and you called 911 for an ambulance but when the ambulance arrived you were told by the ambulance provider that you had a choice to go to the hospital or stay home. You say that you are 87 years old, have a limited income and in poor health. The Plan denied your request. The Plan says if you refuse ambulance transport or your care is stabilized, and you are not transported to a facility, ambulance services will not be covered.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   

The ambulance company did not provide transport services on August 13, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 

Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on July 28, 2020, to November 12, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for dental services. You say that these services were required. The Plan denied your request. The Plan says there are in-network providers available who could have provided these 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 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 dental services provided on July 28, 2020, to November 12, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening digital breast tomosynthesis (77063) and screening mammography (77067 provided August 5, 2021.
You asked the Plan to pay for the screening mammography. You say that it is not fair and you should not be billed for this. They should have contacted the insurance company before this visit because now they want to charge you. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.
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. In this case, Medicare covers mammogram screening to check for breast cancer once every 12 months. The records show that this service was already provided on date of service March 31, 2021 by another provider. Therefore, this benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the screening digital breast tomosynthesis (77063) and screening mammography (77067 provided August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for routine electrocardiogram (ECG) with at
least 12 leads, including the tracing, interpretation, and report (93000) provided July 12, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you had a full EKG study
at the cost of $60.00. You do not understand why the claim was not paid at full 100%. The Plan denied your
request. The Plan says the claim was processed with the correct copayment applied per the Evidence of
Coverage.
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
copayment for Medicare covered non-radiological diagnostic services.
You have been asked to pay $13.75 for the diagnostic service. Since the allowed amount is less than the
copayment amount, you are responsible for the lesser amount. The diagnostic service 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 routine electrocardiogram (ECG) with at least 12 leads, including the tracing, interpretation, and report (93000) provided July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on November 9, 2020.
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 procedure code 00541 is 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. In this case, the CPT Code Manual definition of code 00541 is anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing 1 lung ventilation. We find that CPT code 00541 is not supported in the medical record. Specifically, there are no medical records supporting that the service was performed for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on November 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and services provided from February 27, 2021, to March 8, 2021.

You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that the enrollee was initially in the hospital from February 16, 2021, until February 27, 2021. Because the enrollee was transferred directly from one hospital to another, you feel only the initial copayment from the first admission should apply. The Plan denied your request. The Plan says this claim was processed correctly and in accordance with the enrollee's contract. The enrollee was transferred to a new level of care on the first date in question. This is considered a new admission, and a new copayment applies.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $275 copayment for each of the first five days of Medicare-covered hospital care. There is a $0 copayment for additional Medicare-covered days. For inpatient hospital care, the cost-sharing described applies each time you are admitted to the hospital. A transfer to a separate facility type (such as an inpatient rehabilitation hospital or long-term care hospital) is considered a new admission.

The enrollee has been asked to pay a $1,375 copayment for the inpatient rehabilitation stay which exceeded five days. This cost sharing applies every time the enrollee is admitted to the hospital, including a transfer to a separate facility type. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehabilitation admission and services provided from February 27, 2021, to March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 24, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the head or brain (70450) provided on July 14, 2021.

You asked the Plan to waive the copayment for a CT scan of the head or brain. You say that you do not think you received a thorough scan and so are appealing the entire amount charged for the scan. The Plan denied your request. The Plan says the correct copayment 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 $225 copayment for CT scans. 

You have been asked to pay a $104.44 copayment for a CT scan of the head or brain. A CT scan of the head or brain falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay less than or equal to the full and 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. Health plans are not required to waive this cost sharing when there is dissatisfaction with the quality of care received. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the head or brain (70450) provided on July 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound of extremity arteries (93922) and an ultrasound of hemodialysis access (93990) provided on May 12, 2021.
You asked the Plan to pay for ultrasounds of extremity arteries and of hemodialysis access. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the request is a duplicate of a prior claim.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ultrasounds of extremity arteries and of hemodialysis access have not been met. Specifically, the Plan has documented that the claim at issue is a duplicate of a prior claim that has been processed and paid.
Therefore, we decided that the Plan does not have to pay for an ultrasound of extremity arteries (93922) and an ultrasound of hemodialysis access (93990) provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services (36415, 80053, 83880, 84443, 85025) provided on August 20, 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 $10 copayment for each covered laboratory service. This copayment may not apply if you visit a primary care physician (PCP) or specialist on the same date of service that the laboratory service was performed, and your plan has an office visit copay for that visit. You have been asked to pay a $10 copayment for the laboratory services provided. Although, the record indicates that you had an office visit with your primary care physician on the same date that the laboratory services were performed, it does not appear that the Plan has applied a copayment for the office visit 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 laboratory services (36415, 80053, 83880, 84443, 85025) provided on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of your and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99100, 99140) provided on July 13, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical records provided. The Plan denied your request. The Plan says no separate payment is made for this service per Medicare.
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 99100 and 99140 are not eligible for separate payment per Medicare rules.
Specifically, per the Physician Fee Schedule, CPT code 99100 and 99140 have a status indicator of B. This means that the payment for these CPT codes is always bundled into the payment for another service and not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99100, 99140) provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on August 23, 2021 by an out-of-network (OON) provider.
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 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 drug testing provided on August 23, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Labetalol.

You asked the Plan to pre-approve Labetalol. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 pre-approve Labetalol.

Benefits for Labetalol 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 20, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the clinical social worker will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the unspecified adjunctive service (D9999), periapical x-ray (D0220), additional periapical x-ray (D0230 x 2), prophylaxis (D1110), oral exam (D0120), and fluoride varnish (D1206 x 2) provided on March 2, 2021.

You asked the Plan to reimburse you for the dental services. You say that it is not fair for you to have to change dentists in order to have coverage. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services received from a dentist that has opted out of Medicare.

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, dental services received from a dentist that hast opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the unspecified adjunctive service (D9999), periapical x-ray (D0220), additional periapical x-ray (D0230 x 2), prophylaxis (D1110), oral exam (D0120), and fluoride varnish (D1206 x 2) provided on March 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasonic guidance for needle placement (76942) provided on July 20, 2021.
You asked the Plan to waive the copayment for the ultrasonic guidance for needle placement. You say that you don't know what this procedure was, and you refuse to pay this copayment. The Plan denied your request. The Plan says this procedure is the use of an ultrasound to guide an injection. Medical records from your provider verify that "the nerves were identified using ultrasound imagery". This claim was processed correctly, and your cost-sharing was assessed in accordance with your contract. Because the Plan's allowed amount (discounted rate) for this service is less than the required payment, you are being asked to pay the lesser 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 $60 copayment for Medicare-covered x-rays and ultrasounds. You have been asked to pay a $60 copayment for the ultrasonic guidance for needle placement. Ultrasonic guidance for needle placement falls within the Medicare-covered x-rays and ultrasounds 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 ultrasonic guidance for needle placement (76942) provided on July 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the retainers - porcelain/ceramic for resin bonded fixed prosthesis (D6548), and pontics - porcelain/ceramic (D6245) provided April 19, 2021.  

You asked the Plan to provide additional payment for the retainers and pontics. You say that you were told 30% of the cost would be covered. The Plan denied your request. The Plan says the claims have been reprocessed to with the Plan covering 30% of the cost. The cost sharing has now been applied correctly.  

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 the retainers and pontics with 70% coinsurance.   

We looked at the file and Medicare rules. The Plan provided documentation showing that your claims have been reprocessed and you have been asked to pay 70% coinsurance for the retainers and pontics. Therefore, we decided that the Plan does not have to provide additional payment for the retainers - porcelain/ceramic for resin bonded fixed prosthesis (D6548), and pontics - porcelain/ceramic (D6245) provided April 19, 2021.