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

We decided that the Plan does not have to waive the copayment for a podiatry visit provided on October 26,
2021.

You asked the Plan to waive the copayment for the podiatry visit. You say that your EOC shows a $0
copayment. 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 $15
copayment for each podiatry visit, including routine foot care for members with certain medical conditions
affecting the lower limbs.

You have been asked to pay a $15 copayment for the podiatry visit. The podiatry visit falls within the Podiatry 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 a podiatry visit provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) and crown (D2740) provided on September 7, 2021.
You asked the Plan to pay for the dental services. You say that the dental office was unaware of the changes in your dental coverage. You also say that you were under the impression you had been paying for dental coverage. The Plan denied your request. The Plan says periapical x-ray and 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 periapical x-ray and crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) and crown (D2740) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on September 28, 2021.
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that the claim should be paid in full since it was a televisit, not in person. 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 visit, including telehealth visits.
You have been asked to pay a $30 copayment for the specialist telehealth visit. The specialist telehealth 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 telehealth visit provided on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for ambulance transportation services, an
inpatient hospital stay, office visits, and home infusion therapy provided from July 16, 2021, to October 15,
2021
You asked the Plan to waive the cost-sharing for the ambulance transportation services, an inpatient hospital
stay, office visits, and home infusion therapy. You say that the services should be covered. The Plan denied
your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for ambulance transportation, a $365 copayment for days 1 to 5 of inpatient hospital care, a $35 or
$30 copayment for Physician/Practitioner services, including doctor's office visits, and a 20% coinsurance for
home infusion therapy.
You have been asked to pay a total of $2,163.95 for all of the services provided. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the cost-sharing for ambulance transportation services, an inpatient hospital stay, office visits, and
home infusion therapy provided from July 16, 2021, to October 15, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatment provided on
July 14, 2021.
You asked the Plan to pay for chiropractic manipulative treatment. The Plan denied your request. The Plan says
prior authorization was not obtained by the provider.
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 chiropractic manipulative treatment provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0483) provided March 12, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.  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 G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the records (11, office). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hematoma drainage procedure performed
on January 14, 2021.
You asked the Plan to waive the copayment for the drainage procedure. You say that previous aspirations were
done previously with no charges. 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 $350
copayment per day for outpatient procedures and services.
You have been asked to pay a $350 copayment for the drainage procedure. The drainage procedure falls within
the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers benefit category. Please note that the Plan's decision on the previous appeal indicated that the
copayment would apply for future procedures. 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 hematoma drainage procedure
performed on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00140 provided on May 20,
2021.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 00140 is anesthesia for procedures on eye; not otherwise
specified.
We find that CPT code 00140 is not supported in the medical record. Specifically, the documentation shows
that this code was billed with procedure code 66982 (Extracapsular cataract removal with insertion of
intraocular lens prosthesis) and 66984 (Extracapsular cataract removal with insertion of intraocular lens
prosthesis). Anesthesia code 00140 has a base value of 5. The correct anesthesia code which should be billed
with these services is 00142, which has a base value of 4. Based on this information, we decided that Medicare
rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not
have to pay for the anesthesia services coded 00140 provided on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the platelet rich plasma injections provided on May 14, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the clinical
effectiveness has not been demonstrated in peer reviewed literature.
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 pay for the services provided. Our physician
reviewer found that the enrollee has androgenetic alopecia. The review has determined that the services at issue
in this case are not medically reasonable or necessary to treat the enrollee's condition.
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 provided have not been met. Therefore, we decided that the Plan
does not have to pay for the platelet rich plasma injections provided on May 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 16, 2021, to August 19, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told you would only have to pay for the first five days. The Plan denied your request. The Plan says the correct copayment has been applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.    You have been asked to pay a $95 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $285 ($95 x 3 days = $285). The correct copayment has been applied to the inpatient hospital stay services that were provided. An inpatient hospital stay 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 an inpatient hospital stay provided by a participating provider on August 16, 2021, to August 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Specialty Care Transport (SCT) hospital-to-hospital transportation of a critically injured or ill beneficiary by a ground ambulance (A0434, A0425) provided on March 10, 2021.
You asked the Plan to pay for Specialty Care Transport (SCT) hospital-to-hospital transportation of a critically injured or ill beneficiary by a ground ambulance. The Plan denied your request. The Plan says the enrollee's claims history indicates they were in an inpatient hospital status on this date of service. Ambulance services used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment for example is considered part of the inpatient admission, and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that transportation from one hospital to another is
considered "patient transportation" and is covered as an inpatient hospital service. We looked at the file and Medicare rules. In this case, the documentation has determined the enrollee was transported to another facility temporarily for care. This is not separately payable from the inpatient services according to Medicare rules. Therefore, we decided that the Plan does not have to pay for Specialty Care Transport (SCT) hospital-to-hospital transportation of a critically injured or ill beneficiary by a ground ambulance (A0434, A0425) provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on October 5, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this code is not paid separately.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 99100 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. 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 the anesthesia services provided on October 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on May 13, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the testing is not supported in the enrollee data.
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 87798 is infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism.
We looked at the file and the rules. We find that CPT code 87798 was billed with a 91 modifier. The records provided do not show that the testing at issue was a repeat laboratory test performed on the same day for the enrollee.
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 the lab testing services provided on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from  December 29, 2020, through December 30, 2020.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support medical necessity for inpatient hospitalization. A lower level of care such as observation beyond emergency room care may have been an option for 24-hours.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is a 71-year-old male who presented with intermittent chest discomfort for past 2 months, admitted with atrial fibrillation. He was treated with IV diltiazem with benefit and was later transitioned to oral. The enrollee's vitals were stable at the time of admission, and he was responding to initial treatment without complication. Workup did not reveal another acute condition or complexities that would warrant inpatient services. Upon admission there was insufficient expectation that the enrollee would require inpatient services that would likely cross 2 midnights.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 29, 2020, through December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office (99214) and the destruction of benign lesions (17110) rendered by the out-of-network (OON) provider on September 1, 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 (99214) and the destruction of benign lesions (17110) rendered by the out-of-network (OON) provider on September 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with specimen collection (45378) provided on August 16, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you were told all the charges for this service would be covered. 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 $250 copayment for diagnostic colonoscopy services provided in an ambulatory surgical center or outpatient hospital setting.   You have been asked to pay a $250 copayment for the diagnostic colonoscopy. 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 diagnostic colonoscopy with specimen collection (45378) provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit provided on September 9, 2021.

You asked the Plan to pay for the services provided. You say that the same claim was processed in 2020 with no enrollee responsibility. The Plan denied your request. The Plan says you have exceeded your benefit limit for this service.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

We looked at the file and the rules. You received an annual wellness visit on September 9, 2021. You previously received this service on February 26, 2021. Your Plan only covers this service once every 12 months. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services received on September 8, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.
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 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 imaging services received on September 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 21, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be
billed to the primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the
Plan does not have to pay for the services provided on September 21, 2021.