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

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 15, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that it is being billed incorrectly. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for each specialist office visit, including surgery services furnished in a physician's office.
You have been asked to pay a $30 copayment for the specialist office visit. Specialist office 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 copayment for a specialist office visit provided on June 15, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the positron emission tomography (PET) scan you had on April 13, 2021.
You asked the Plan to waive the coinsurance for the PET scan. You say that you have metastatic melanoma and the PET scans are vital to your treatment. You stated that this copayment is a financial hardship for you. 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 10% coinsurance for diagnostic radiology and complex imaging services. You have been asked to pay 10% coinsurance for the PET scan. The PET scan falls within the diagnostic radiology and complex imaging 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 coinsurance for the positron emission tomography (PET) scan you had on April 13, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening (81355, 81401) provided on February 26, 2021.
You asked the Plan to pay for genetic screening. You say that this was medically necessary. The Plan denied your request. The Plan says this testing is not covered for the enrollee's condition.
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, genetic screening, was requested solely for screening purposes, as it was ordered with diagnosis Z13.79, encounter for other screening for genetic and chromosomal anomalies. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening (81355, 81401) provided on February 26, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services (17004, 11102, 11103, 99213) provided June 21, 2021.
You asked the Plan to pay for the dermatology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider has opted out of Medicare and is not eligible for payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dermatology services (17004, 11102, 11103, 99213) provided June 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of
the head provided on July 7, 2021, billed with code 70450-26.
You asked the Plan to pay for the billed code 70450. You say that this should be paid as multiple exams were
performed on the same date of service. The Plan denied your request. The Plan says a valid modifier was not
used to allow payment on this code.
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 the billed
code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for the interpretation of the computed tomography
(CT) scan of the head provided on July 7, 2021, billed with code 70450-26
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient services provided from May 28, 2021, to June 7, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that it was your understanding that for the first 20 days of rehab, there are no charges to you. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with 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 $345 copayment for each of the first five days of inpatient hospital care. There is a $0 copayment for additional days.
Your inpatient cost share will begin on day one each time you are admitted or transferred to a specific facility type, including Inpatient Rehabilitation facilities, Long Term Acute Care facilities, Inpatient Acute Care facilities and Inpatient Psychiatric facilities. You have been asked to pay $1,725 for an inpatient stay which exceeded five days ($345 x 5 = $1,725). 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 inpatient services provided from May 28, 2021, to June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology gene expression testing provided on June 23, 2021.
You asked the Plan to pay for the oncology gene expression testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 oncology gene expression testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the oncology gene expression testing provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen panel provided on August 25, 2020.
You asked the Plan to pay for the respiratory pathogen panel. You say that this was medically necessary and
should be covered. The Plan denied your request. The Plan says this was not billed with an appropriate POS
code because the sample was taken in the nursing facility setting.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory
directly.
We looked at the file and Medicare rules. The documentation does not indicate this sample was taken by the
lab directly. As such, the use of POS code 81 is not supported. Based on this information, we decided that
Medicare rules for coverage of the respiratory pathogen panel have not been met. Therefore, we decided that
the Plan does not have to pay for the respiratory pathogen panel provided on August 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on June 26, 2020.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate when services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and interpretation (D0364) provided on August 9, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that the regular x-ray was not effective which is why the CT was ordered, which showed the infection. You also say that you would like for the CT to be paid because it was the best diagnosis tool. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 cone beam computed tomography (CT) capture and interpretation (D0364) provided on August 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck
(76536) provided on July 22, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the cost-share for this service was
lower in previous years. The Plan denied your request. The Plan says this claim was processed correctly, and
your copayment was assessed in accordance with your 2021 contract. The cost share for ultrasounds changed
from 20% coinsurance in 2019 to a $105 copayment in 2020. This information was provided in the 2020
Annual Notice of Changes.
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 $105
copayment for Medicare-covered radiological diagnostic services other than x-rays.
You have been asked to pay a $105 copayment for the ultrasound. An ultrasound falls within the Medicare-covered radiological diagnostic 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 ultrasound of the head and neck (76536) provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered from April 24, 2021 to April 27, 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 procedure code 99233 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 99233 is Level 3 subsequent hospital care for evaluation and management of patient, including detailed interval history and medical decision making of moderate complexity, typical time 35 minutes. We find that CPT code 99233 is not supported in the medical record. Specifically, there is no documentation of 35 minutes of Level 3 subsequent hospital care for the dates 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 subsequent hospital care rendered from April 24, 2021 to April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the neurology office visits you had on May 10, 2021, and June 21, 2021.
You asked the Plan to waive the copayments for the neurology visits. You say that you are on a limited income and believed your cost sharing would be $0. 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 $20 copayment per visit for specialist visits.
You have been asked to pay a $20 copayment per visit for the neurology visits. The neurology visits fall within the specialist 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 the neurology office visits you had on May 10, 2021, and June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a battery charger for a wheelchair provided on May 13, 2021.
You asked the Plan to pay for a battery charger for a wheelchair. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order or proof delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for a battery charger for a wheelchair provided on May 13, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the allowed amount for the porcelain crown (D2740) and abutment supported crown (D6058) provided on July 21, 2021, by the out of network provider.
You asked the Plan to reimburse the allowed amount for the dental services. You say that this out of network provider was used because this work was beyond the expertise or desire of the in network providers. You also say that you are requesting reimbursement of the amount allowed by the Plan. The Plan denied your request. The Plan says the porcelain crown and abutment supported crown are not listed as covered services.
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 porcelain crown and abutment supported crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse the allowed amount for the porcelain crown (D2740) and abutment supported crown (D6058) provided on July 21, 2021, by the out of network provider
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 August 6, 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 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 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 August 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429) provided on November 21, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should owe a lesser copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with 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 $205 copayment for ambulance services. You have been asked to pay a $205 copayment for the ambulance transportation. 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 ambulance transportation services (A0429) provided on November 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic agent(s) and/or steroid injection coded 64415 provided on March 5, 2021.
You asked the Plan to pay for the anesthetic agent(s) and/or steroid injection. 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 64415 for the anesthetic agent(s) and/or steroid injection is a column II code to column I code 01810. 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 anesthetic agent(s) and/or steroid injection coded 64415 provided on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne testing provided on May 25, 2021.
You asked the Plan to pay for the testing services. You say that the test is medically necessary to identify target therapy options. The Plan denied your request. The Plan says the testing is unlikely to impact decision making.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the results of the testing would be used in the management of a specific medical problem. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne testing provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam and eye refraction provided on July 12, 2021 and does not have to pay an additional amount for eyeglasses provided on July 12, 2021.
You asked the Plan to pay for the eye exam and to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says there was no health Plan authorization to see a non-Medicare Advantage network provider. Your care could have been provided by another provider who is within his network. Also, the Plan paid the eyewear benefit maximum amount of $350, and you are responsible for the balance of $14 that exceeds this amount.
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.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the eye exam. We found no exception that would require the Plan to pay for the eye exam. Therefore, we decided that the Plan does not have to pay for an eye exam and eye refraction provided on July 12, 2021. Also, the Plan paid the eyewear benefit maximum amount of $350, and you are responsible for the balance of $14 that exceeds this amount. Therefore, the Plan does not have to pay an additional amount for eyeglasses provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285, 93010) provided on June 10, 2021.
You asked the Plan to pay for an emergency room visit. You say that this visit met requirements for coverage. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.
We looked at the file and Medicare rules. The billed primary, first-listed diagnosis, E08.10, diabetes mellitus due to underlying condition with ketoacidosis without coma, is a manifestation code that requires the underlying condition to be sequenced first. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285, 93010) provided on June 10, 2021.