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

We decided that the Plan does not have to waive the copayments for specialist visits provided on June 9, 2021, and July 28, 2021.
You asked the Plan to waive the copayments for specialist visits. You say that you were told you would not owe a copayment for follow-up visits. 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 $35 copayment for specialist visits. You had follow-up visits on June 9, 2021, and July 28, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $70. You have been asked to pay the total copayment amount of $70 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for specialist visits provided on June 9, 2021, and July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the contrast material used during a
positron emissions tomography (PET) scan you had on March 23, 2021.

You asked the Plan to waive the coinsurance for the contrast material. You say that you should not have
separate coinsurance for the contrast material. You stated that it should be included in the copayment for the
PET scan itself. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for medical supplies.

Your contract explicitly says that chemical agents used in diagnostic procedures are subject to separate cost
sharing as a medical supply. You have been asked to pay 20% coinsurance for the contrast material. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for the contrast material used during a positron emissions
tomography (PET) scan you had on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmological medical examination and evaluation
(92014) and the scanning computerized ophthalmic diagnostic imaging (92133) rendered by the out-of-network
(OON) provider on April 9, 2021.

You asked the Plan to pay for these 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 ophthalmological medical examination and evaluation (92014) and the
scanning computerized ophthalmic diagnostic imaging (92133) rendered by the out-of-network (OON)
provider on April 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on July 5, 2021.
You asked the Plan to pay for the CT. 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 for the CT 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. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on July 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on December 1, 2020.
You asked the Plan to pay for the therapeutic procedure. 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 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, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that these services were performed by a physical therapist assistant in a home health or hospice setting. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental consultation and cone beam CT you received on
July 23, 2021.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services
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 services are not among
those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage.
Dental consultations and cone beam CT are not covered. Therefore, we decided that the Plan does not have to
pay for the dental consultation and cone beam CT you received on July 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from February 1, 2021, to February 12, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you did not want to stay there and you cannot afford this copayment. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services. Records show that you were in the SNF from January 12, 2021, to February 12, 2021, for a total of 31 days.
You were not charged a copayment for the first 20 days of this stay. For the remaining 11 days of the stay, you were charged a copayment of $184 per day, for a total of $2024. 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 skilled nursing facility (SNF) services you received from February 1, 2021, to February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for flow cytometry (88184) provided on August 24, 2020.
You asked the Plan to pay for flow cytometry. You say that this should be covered. The Plan denied your request. The Plan says this was not performed.
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 88184 is flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker. We find that CPT code 88184 is not supported in the medical record. Specifically, the record indicates that flow cytometry was not performed. Based on this information, we decided that Medicare rules for coverage of
flow cytometry have not been met. Therefore, we decided that the Plan does not have to pay for flow cytometry (88184) provided on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99211 x 2), the therapeutic, prophylactic, or diagnostic injection (96372), and the haloperidol decanoate injection (J1631) rendered by the out-of-network (OON) provider on May 4, 2021 and May 18, 2021.
You asked the Plan to pay for these 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 office visits (99211 x 2), the therapeutic, prophylactic, or diagnostic injection (96372), and the haloperidol decanoate injection (J1631) rendered by the out-of-network (OON) provider on May 4, 2021 and May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head
rendered on August 24, 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 the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70544 (MRA head) and 70551 (magnetic resonance
imaging of the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with
column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the
head rendered on August 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 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 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, a cardiovascular risk assessment panel, 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 August 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compounded drug (J7999) provided on January 25, 2021.
You asked the Plan to pay for the compounded drug. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says when using a not otherwise classified (NOC) code, a comment or remark identifying service must be included on claim.
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 J7999 is compounded drug, not otherwise classified. We find that CPT code J7999 is not supported in the record. Specifically, this claim was billed with a NOC code. The claim does not include a remark identifying what this code represents. Based on this information, we
decided that Medicare rules for coverage of the compounded drug have not been met. Therefore, we decided that the Plan does not have to pay for the compounded drug (J7999) provided on January 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 19, 2021.
You asked the Plan to pay for the comprehensive evaluation. You say that you were told this was an in-network provider and believed this service would be covered. You feel the Plan has made a mistake. The Plan denied your request. The Plan says one comprehensive oral evaluation can be covered every three plan years. You had a previous comprehensive exam less than three years ago which was covered by the Plan at that time. Therefore, your benefit for this service was exceeded on the date in question, and payment will not be made.
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 can cover one comprehensive exam (D0150) every three plan years.
Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive oral exam is requested in a frequency that exceeds what is covered under this benefit. Documentation shows that the Plan paid for a previous comprehensive evaluation for you in October of 2020, which is less than three years before the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 19, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit you had on June 4, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you believe there is a $0 copayment for urgent care services. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that the claim for the $65 copayment will be filed with your Medicaid benefits and you will have no responsibility for the claim once that is done.
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 $0-$65 copayment for urgent care services.
You have been asked to pay a $0-$65 copayment for the urgent care visit. According to your contract, you will pay a $65 copayment unless you are a Medicare-Medicaid dual eligible enrollee. If you are, the copayment still applies, but your Medicaid coverage will cover the cost sharing. In this case, the Plan has confirmed that your provider is submitting this $65 charge to Medicaid and you will not be responsible for the balance. Therefore, we decided that the Plan does not have to waive the copayment for the urgent care visit you had on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the zoster vaccine and immunization administration provided on July 13, 2021.

You asked the Plan to pay for the zoster vaccine and immunization administration. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the vaccine you received is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the zoster vaccine and immunization administration. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the zoster vaccine. Therefore, we decided that the Plan does not have to pay for the zoster vaccine and immunization administration provided on July 13, 2021.

Benefits for the zoster vaccine and immunization administration 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the recementing or re-bonding of crown (D2920) and limited oral evaluation (D0140) provided on July 7, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary. The Plan denied your request. The Plan says the recementing or re-bonding of a crown is not covered by your dental benefit, and you have exceeded your benefit limitation for the limited oral evaluations.
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. Services and codes not listed in the Plan's dental benefit chart are not covered. The Plan can cover one limited exam to evaluate a problem (D0140) per plan year.
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 or are requested in a frequency that exceeds what is covered by this benefit. Documentation shows that you had a previous limited oral exam in May of 2021, which was covered by the Plan at that time. Therefore, we decided that the Plan does not have to pay for the recementing or re-bonding of crown (D2920) and limited oral evaluation (D0140) provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on July 27, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says you do not have out-of-network Plan benefits to reimburse for a refraction.

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 eye refraction provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 14, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you 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 $25 copayment for each specialist visit. You have been asked to pay a $25 copayment for a specialist visit. A specialist 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 visit provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (93000, 99214, G8427) provided on May 11, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.
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 office visit (93000, 99214, G8427) provided on May 11, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from October 6, 2020 to June 16, 2021.
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan denied your request. The Plan says you 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 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 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 physician services provided from October 6, 2020 to June 16, 2021.