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

 We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 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 claim was billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  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. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided May 27, 2021, and comprehensive oral evaluation - new or established patient (D0150) and bitewings - three radiographic images (D0273) provided June 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to provide additional payment for the limited oral exam, intraoral x-rays, comprehensive oral exam and bitewing x-rays. You say that when you were signed up you weren't told about in and out-of-network coverage. The Plan denied your request. The Plan says the OON enrollee liability was applied correctly per the enrollee's plan benefits.  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 limited oral exam, intraoral x-rays, comprehensive oral exam and bitewing x-rays when the services are medically necessary and reasonable. If you choose to see an OON dentist, you might be billed for any amount greater than what the Plan pays.  We looked at the file and Medicare rules. The Plan has covered the requested services up to the Plan's allowed amount. Therefore, we decided that the Plan does not have to provide additional payment for the limited oral evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220), and intraoral - periapical each additional radiographic image (D0230) provided May 27, 2021, and comprehensive oral evaluation - new or established patient (D0150) and bitewings - three radiographic images (D0273) provided June 30, 2021, by an out-of-network (OON) provider.   Your complaint about potentially not being provided complete information when you signed up for your Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for an excision (23150-59) provided on March 12, 2021.  You asked the Plan to pay for an excision. You say that the use of modifier -59 unbundles this service. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 an excision Our reviewer says that the use of modifier -59 is not supported. Our physician reviewer found the record does not indicate that intraoperative pathology report was requested or obtained that impacted the remainder of the procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an excision have not been met. Therefore, we decided that the Plan does not have to pay for an excision (23150-59) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit you had with your primary care provided on May 25, 2021.  You asked the Plan to waive the copayment for the office visit. You say that this was your annual wellness visit, so there should be no 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 $10 copayment for primary care office visits.   According to your contract, an annual wellness visit (for which there is no copayment), only includes services to develop or update a personalized prevention plan based on your current health and risk factors.  An annual wellness exam does not include evaluation or treatment of a specific condition.  We looked at the medical records from this visit.  According to the records, in addition to the annual wellness visit services, your doctor evaluated you for complaints of allergy symptoms.  Specifically, you advised that you were experiencing congestion with an inability to blow your right nostril. As a result of the doctor's evaluation for this condition, your doctor prescribed montelukast to you.  These services related to the evaluation and treatment of allergies are beyond the scope of an annual wellness exam, which is why the primary care office visit copayment applies. 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 office visit you had with your primary care provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 25, 2021.  You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are missing required information.  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 code 81479 is not supported in the medical record. Specifically, the documentation shows that the appropriate DEX Z code was not entered to the code billed in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 25, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on June 20, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER because of hip pain. You had to return to the ER on the same day.  You don't think you should have to pay the copayment because the diagnoses from the two hospitals were different. 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 $120 copayment per visit for emergency room services.   You have been asked to pay a $120 copayment per visit for the ER visit. This copayment applies regardless of the outcome of the 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 the emergency room (ER) visit you had on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ophthalmological services, medical examination and evaluation provided on June 4, 2021.  You asked the Plan to waive the copayment for ophthalmological services, medical examination and evaluation. You say that you had a routine eye exam, and your copayment should be $20. The Plan denied your request. The Plan says the medical documentation provided documents that you have cataracts in both eyes at this visit and assessed them to be mild with minimal impact on vision. The provider also noted dryness in your eyes, which you use artificial tears as needed. The claim submitted your medical eye benefit accurately according to your contract.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information  (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for Vision Care, Medical Eye Exam.  You have been asked to pay a $50 copayment for the ophthalmological services, medical examination and evaluation. The ophthalmological services, medical examination and evaluation falls within the Vision Care, Medical Eye Exam 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 ophthalmological services, medical examination and evaluation provided on June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 12, 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 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 70470 (CT head/brain) and 70496 (computed tomography angiography). Code 70470 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70470 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 computed tomography (CT) scan of the head/brain rendered on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the transthoracic echocardiography (TTE) and the non-invasive arterial studies you had on May 13, 2021.  You asked the Plan to waive the deductible for the TTE and the non-invasive arterial studies. You say that these tests were not necessary, and you don't think you should have to pay the deductible. The Plan denied your request. The Plan says you were charged this deductible correctly.  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 $500 deductible which applies to outpatient diagnostic testing.   The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic testing. This cost sharing applies regardless of your satisfaction with the services. This cost sharing is a contractual obligation that had not been met at the time the TTE and the non-invasive arterial studies was received on May 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the transthoracic echocardiography (TTE) and the non-invasive arterial studies you had on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the complete series x-ray (D0210) provided on April 27, 2021.  You asked the Plan to waive the cost share for the dental service. You say that you have never had to pay for the x-ray in the past. You also say that you should not have to pay for it now either. The Plan denied your request. The Plan says there is a $100 deductible that applies to Class 2 Basic Services before the coinsurance can be applied. The Plan says that the deductible had not been reached prior to receiving the x-ray. The Plan also says that the claim was processed 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the deductible had not been reached prior to receiving the x-ray. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost share for the complete series x-ray (D0210) provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on March 5, 2021.  You asked the Plan to pay for the hospital discharge day management. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says one hospital discharge is allowed per stay.  The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management service is payable per patient per hospital stay.   We looked at the file and Medicare rules. The record shows that a hospital discharge day management Current Procedural Terminology (CPT) code 99238 was billed for March 5, 2021 and was processed for payment. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a bone replacement graft (D4263) provided by an out-of-network provider on July 28, 2021.  You asked the Plan to pay for a bone replacement graft. You say that you do not agree with being charged this amount. The Plan denied your request. The Plan says the dental service that was provided is not a covered 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 a bone replacement graft (D4263) provided by an out-of-network provider on July 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on March 26, 2020.  You asked the Plan to waive the copayment for the ambulance services. You say that these services should be covered because you are bed-bound and on Social Security. You said that you needed to use gurney transportation to return home from the emergency room. 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 $195 copayment per trip for ambulance services.   You have been asked to pay a $195 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on March 26, 2020.
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 November 1, 2020, to November 6, 2020.  You asked the Plan to waive the copayment for the SNF services. You say that this should be paid in full. 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 $160 copayment per day for days 21-100 for skilled nursing facility services.   Records show that you were in the SNF from October 13, 2020, to November 6, 2020, for a total of 24 days. You were not charged a copayment for the first 20 days.  You were charged a $160 copayment for the remaining 4 days, for a total of $640. 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 November 1, 2020, to November 6, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (92532) provided July 15, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the billed code is not eligible for separate payment.

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 code 92532 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule, the code billed has a status of "B" and payment is bundled in payment for another service. Based
on this information, we decided that Medicare rules for coverage of the physician services have not been met.
Therefore, we decided that the Plan does not have to pay for physician services (92532) provided July 15,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of an adequate trial and failure of physical therapy for back pain. There are no red flags for emergent surgery. More conservative measures are needed. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug and outpatient hospital services provided on May 18, 2021.
You asked the Plan to pay for the self-administered drug. You say that the services should be covered. The Plan denied your request. The Plan says the claim was processed correctly as self-administered drug is 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 drug and outpatient hospital services provided on May 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services provided on May 29, 2021.

You asked the Plan to pay for the therapeutic services. The Plan denied your request. The Plan says this provider is not considered a qualified healthcare provider that is practicing under one of the accepted licenses. The Plan also says that it is important to know which providers are part of our network because, with limited exceptions, while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.

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 therapeutic services provided on May 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the outpatient surgery you had at an ambulatory surgery center on February 4, 2021.  You asked the Plan to waive the coinsurance for the outpatient surgery. You say that you should not have to pay this coinsurance since your surgery was originally scheduled for December of 2020.  You said that this surgery had to be moved to February due to your COVID-19 diagnosis. 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 outpatient surgery at an ambulatory surgery center.   You have been asked to pay 20% coinsurance for the outpatient surgery. You had this service in 2021, so this cost sharing applies, regardless of why your procedure may have been delayed. 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 outpatient surgery you had at an ambulatory surgery center on February 4, 2021.