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

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on
September 17, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that the service provided was
preventative service with no copayment. The Plan denied your request. The Plan says the provider records state
this was not a preventative colonoscopy it was done as a diagnostic due to having a history of polyps and a
preventative service is done every 5 years. Therefore, the proper copayment was 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 $340
copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility.
You have been asked to pay a $340 copayment for the colonoscopy. The colonoscopy falls within Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 diagnostic colonoscopy provided on
September 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you
received from January 3, 2021, to January 27, 2021.
You asked the Plan to waive the copayment for the SNF services. You did not provide an argument with your
appeal request. 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 $176 copayment per day for days 21-100 for SNF services.
Records show that you were in the SNF for 25 days. You were not charged a copayment for the first 20 days.
For the remaining 5 days, you were charged a copayment of $176 per day, for a total of $880.
You have been asked to pay a $0 copayment for days 1-20, and a $176 copayment per day for days 21-100 for
the SNF services. 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 January 3, 2021, to January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110),
and a crown (D2740) provided by a participating provider on January 11, 2021, to January 19, 2021.
You asked the Plan to pay for a periodic oral evaluation, prophylaxis, and a crown. You say that you would like
the Plan to pay for this. The Plan denied your request. The Plan says the dental services that were provided are
not covered dental 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 a periodic
oral evaluation (D0120), prophylaxis (D1110), and a crown (D2740) provided by a participating provider on
January 11, 2021, to January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetic testing services provided on June 16, 2021.

You asked the Plan to pay for the testing services. You say that the documents show medical necessity. The Plan denied your request. The Plan says a panel of tests should be billed under a single code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. The file shows that the testing panel was billed with multiple codes. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. 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 pharmacogenetic testing services provided on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that the requested compression stockings are medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not covered by Medicare.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate for your use, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on June 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that services were rendered to the enrollee for a definitive test so payment should be made. The Plan denied your request. The Plan says the referring physician is an out-of-network physician, and the provider is a non-participating provider. The services rendered were not urgent or emergent, so the claim is denied.  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 laboratory services provided on June 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a nephrology specialist on April 22, 2021.  You asked the Plan to waive the copayment for the telehealth visit with a specialist. You say that you were told that all copayments for telehealth visits were waived through the end of April 2021. 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 $30 copayment for specialist visits (including telehealth visits).   You have been asked to pay a $30 copayment for the telehealth visit with a specialist. There is nothing in your contract or on the Plan's website stating that specialist telehealth copayments were being waived on this date of service. 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 telehealth visit you had with a nephrology specialist on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical each additional radiographic image
(D0230) provided November 2, 2021.
You asked the Plan to pay for the two additional periapical x-rays. You say that you had to go to a second
dentist due to office closures. The Plan denied your request. The Plan says you have exceeded the frequency
limit for this service.
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 2
additional periapical x-rays once per calendar year.
We looked at the file, and Medicare rules. The Plan provided documentation showing that a periapical x-ray
was covered on the same date of service. Based on this information, we decided that the Plan's frequency limit
for coverage of the periapical x-rays has been exceeded. Therefore, we decided that the Plan does not have to
pay for the intraoral - periapical each additional radiographic image (D0230) provided November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 20, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.

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 a nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine rendered on September 13, 2021.  

You asked the Plan to pay for these services. You say that you would like to be reimbursed. The Plan denied your request. The Plan says the services are not covered.  

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules.   

Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on September 13, 2021.   

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the DecisionDx testing provided on August 31, 2021.  You asked the Plan to pay for the testing services. You say that no other CPT code accurately describes this test. The Plan denied your request. The Plan says that testing should use 1 unit of CPT code 81479.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. We find that CPT code 81599 was reported correctly. The rules say that CPT code 81479 is used if no CPT code accurately describes the procedure performed. Based on this information, we decided that Medicare rules for coverage of the testing services have been met. Therefore, we decided that the Plan has to pay for the DecisionDx testing provided on August 31, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
October 1, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were never given an
option to be transported via other means. You said that, had you known about the copayment, you would have
had your son drive you. 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 $325
copayment for ambulance services.
You have been asked to pay a $325 copayment 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 October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
September 2, 2021.
You asked the Plan to pay for out of network providers. You say that this claim should be paid. The Plan
denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the
enrollee on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited (problem-focused) oral exam (D0140) provided
on May 19, 2021.
You asked the Plan to pay for the limited exam. You say that this service was necessary. The Plan denied your
request. The Plan says this service may only be covered once per plan year. You previously had a limited
(problem-focused) oral exam on May 10, 2021, which was covered by the Plan at that time. The service in
question exceeds the frequency limitations of your dental benefit and is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one limited
exam to evaluate a problem (D0140) per plan year.
Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a
frequency that exceeds what is covered by this benefit. The record shows that you had a previous limited oral
exam in 2021 which was covered by the Plan. Therefore, we decided that the Plan does not have to pay for the
limited (problem-focused) oral exam (D0140) provided on May 19, 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 April 17, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that you were
experiencing violent vomiting, headache, abdominal pain and you were shaking and clammy. You say that by
the time the ambulance arrived and took your vitals, you started to feel better and you declined to go the
hospital due to Coronavirus and you would call again if you felt worse. 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 April 17, 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 April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral radiographic imaging (D0230) provided by a participating provider on September 21, 2021.

You asked the Plan to pay for intraoral radiographic imaging. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0230 has already been exhausted.

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 two intraoral radiographic imaging per year. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of intraoral radiographic imaging have already been met. Therefore, we decided that the Plan does not have to pay for intraoral radiographic imaging (D0230) provided by a participating provider on September 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a colonoscopy with biopsy.  

You asked the Plan to pre-approve colonoscopy. You say that it was recommended that you have a colonoscopy once every 5 to 7 years because you have a family history of colon cancer. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you are not at high risk and there are no symptoms that reflect the need for a colonoscopy at this time.  

The Plan follows Medicare rules. Medicare rules state that screening colonoscopies are covered once every 10 years except in high-risk individuals. 

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 colonoscopy. Our reviewer says that you do not meet the Medicare criteria for the requested colonoscopy. Our physician reviewer found based on the available documentation, you do not have a first-degree relative who has had colorectal cancer or an adenomatous polyp. Therefore, you are not at high risk for colon cancer. You previously had a colonoscopy in 2014. The requested colonoscopy exceeds the frequency limit of once every 10 years.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy with biopsy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from June 17, 2021 to June 20, 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 submitted records do not support the billing of DRG 689 and secondary diagnosis code G93.41.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with. 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 689 and secondary diagnosis code G93.41. Our physician reviewer found the records support an admission for a urinary tract infection and aphasia. The records are inconsistent regarding a diagnosis of encephalopathy. Although encephalopathy is documented, supporting medical documentation is not present within the records. She presented to the emergency department with aphasia and was treated with tissue Plasminogen Activator (tPA). On discharge it was documented that she was "alert and oriented x2" and "mildly confused." The documentation did not support a change in mental status which is beyond baseline. The records do not support the billing of DRG 689 and G93.41.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from June 17, 2021 to June 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Specialty Care Transport (A0424) provided on November 24, 2020.

You asked the Plan to pay for Specialty Care Transport. The Plan denied your request. The Plan says the services are not allowed separately.

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 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 (A0424) provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient surgeries provided from
July 12, 2021, to September 13, 2021.
You asked the Plan to waive the copayments for the outpatient surgeries. You say that you were never told
there would be a copayment for each visit. The Plan denied your request. The Plan says the proper copayment
was applied to each date of 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). Your contract with the Plan clearly says that you must pay a $150
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers. From July 12, 2021, to September 13, 2021, the total copayment amount was
$900 ($150 copayment per visit x 6 visits).
You have been asked to pay a $900 copayment for the outpatient surgeries. The outpatient surgeries fall within
the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory
Surgical Centers 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 outpatient
surgeries provided from July 12, 2021, to September 13, 2021.