Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided June 7, 2021.

You asked the Plan to pay for the core buildup. You say that this service should be covered. The Plan denied your request. The Plan says this service is not covered under your 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided June 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health telehealth services you received from May 12, 2021, to July 7, 2021.
You asked the Plan to waive the copayments for the outpatient mental health telehealth services. You say that you were told that telehealth services were free. The Plan denied your request. The Plan says you were charged these copayments 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 $25 copayment per visit for outpatient mental health services, including telehealth visits. You have been asked to pay a $25 copayment per visit for the outpatient mental health telehealth services. Your contract with the Plan clearly discloses this cost sharing obligation.
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 outpatient mental health telehealth services you received from May 12, 2021, to July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 14, 2021, to May 21, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are self-employed and have no income due to your medical issues. 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 $100 copayment for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from May 14, 2021, to May 21, 2021. Therefore, you are responsible to pay a $100 copayment for days 1-7 (May 14, 2021, to May 20, 2021). However, you are only being asked to pay $500, which is less than the total copayment amount. You have been asked to pay the total copayment amount of $500 for inpatient hospital care. Inpatient hospital
care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 14, 2021, to May 21, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy procedure (0275T).
You asked the Plan to pre-approve the percutaneous laminotomy/laminectomy procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that this procedure is only covered when the enrollee is enrolled in an approved clinical study. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the percutaneous laminotomy/laminectomy procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy procedure (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ostomy supplies you received on January 27, 2020.

You asked the Plan to waive the coinsurance for the ostomy supplies. You say that because the Plan made the mistake on the first claim, that you shouldn't have to pay the coinsurance. The Plan denied your request. The Plan says it originally denied this claim in full in error. The claim has now processed correctly and you have been assessed the correct coinsurance.

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 durable medical equipment and supplies. 

You have been asked to pay 20% coinsurance for the ostomy supplies. This coinsurance applies regardless of when the claim processes. The ostomy supplies fall within the durable medical equipment and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for ostomy supplies you received on January 27, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory work provided on August 26, 2021. 
 
You asked the Plan to pay for the laboratory work. You say that the enrollee was seen by a network physician, 
however, there were no in-network laboratories able to provide the appropriate medical care. The Plan denied 
your request. The Plan says that no prior authorization was obtained. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not show whether the referring provider was an in-network or an 
out-of-network physician. This means we cannot determine if the Plan's denial of the laboratory work was 
supported. Therefore, we decided that the Plan has to pay for the laboratory work provided by Bako Pathology 
Services on August 26, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on June 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet injection provided on April 9, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for facet injection provided on April 9, 2021.
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 May 30, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
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 May 30, 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 May 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on  
June 28, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the code was not bundled with any other procedure 
code performed on the same date of service. The Plan denied your request. The Plan says an appropriate 
modifier was not billed. 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
In this case, the CPT Code Manual definition of code 70450 is computed tomography, head or brain; without 
contrast material. The file shows that code 70450 was billed with code 70496. The rules say that code 70450 
may be eligible for payment when billed with a modifier. The claim provided does not indicate the code at 
issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare 
rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay 
for the computed tomography (CT) scan provided on June 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test you had on June 21, 2021.
You asked the Plan to waive the copayment for the nuclear stress test. You say that you believe you are being charged incorrectly. 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 $60 copayment for nuclear medicine services. You have been asked to pay a $60 copayment for the nuclear stress test. The nuclear stress test falls within the nuclear medicine services 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 nuclear stress test you had on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 11, 2020.
You asked the Plan to pay for an office visit. You say that the Plan has paid for one visit, but not the second visit with your doctor. The Plan denied your request. The Plan says your doctor was not in-network with the Plan until June 1, 2020.
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 record shows that your doctor was not in-network until June 1, 2020, which was after your office visit. At the time of your visit your doctor provider was 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 provided on February 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wheelchair you received on November 19, 2020.
You asked the Plan to waive the coinsurance for the wheelchair. You say that you paid this coinsurance for this chair, but it is now broken. You think you should be reimbursed for the coinsurance because you can't currently use the chair. The Plan denied your request. The Plan says the provider has been trying to work with you on repairs to the chair. The Plan says that 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 durable medical equipment. You have been asked to pay 20% coinsurance for the wheelchair. The wheelchair falls within the durable medical equipment benefit category. This coinsurance applies regardless of the current status of the chair. 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 wheelchair you received on November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy for low back pain treatment.
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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on June 23, 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 domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 18, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the charges are unwarranted and would like to see what providers are in-network. 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 $280 copayment for ambulance services. You have been asked to pay a $280 copayment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on January 18, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular genetic risk assessment panels.
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 for screening purposes. The records do not show that the results of the testing would be used in the management of a specific medical problem. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular screening panel provided on January 18, 2021
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services (88305 x 2) rendered by the out-of-network 
(OON) provider on May 25, 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 that the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for these services by a contract provider. The file does not show that the plan 
provided notice that these services would not be covered. Under Medicare rules, this means these services are 
considered approved by the plan. Therefore, we decided that the Plan has to pay for the laboratory services 
(88305 x 2) rendered by the out-of-network (OON) provider on May 25, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 20, 2021.
You asked the Plan to pay for an office visit. You say that the claim was denied for no primary care physician referral, but that a referral is not available. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization or referral from a contracted provider. The Plan says the services were not urgent or emergent.
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 provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Zometa injection you received on 
August 5, 2021. 
 
You asked the Plan to waive the coinsurance for the Zometa injection. You say that you have this injection 
every 6 weeks and have never had to pay coinsurance before. 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 Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Zometa injection. The Zometa injection falls within the 
Medicare Part B drugs benefit category. This coinsurance applies regardless of whether or not you have been 
charged in the past. 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 Zometa injection you 
received on August 5, 2021.