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

 We decided that the Plan does not have to waive the copayment for the walk-in clinic visit you had on September 3, 2021.  You asked the Plan to waive the copayment for the walk-in clinic visit. You say that you believe the walk-in clinic should be charged like a primary care visit and there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this visit ($48) is less than your copayment, you are responsible for the full allowed 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 $50 copayment for visits to a Convenient Care Center.  You have been asked to pay a $50 copayment for the walk-in clinic visit. The walk-in clinic visit falls within the visits to a Convenient Care Center 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 walk-in clinic visit you had on September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical shoulder arthroscopy (29826) provided on July 8, 2021.  

You asked the Plan to pay for the surgical shoulder arthroscopy (29826). You say that this procedure code has been appended with modifier 59 which states distinct procedural service. You say that the notes should be reviewed, and the claim reprocessed. The Plan denied your request. The Plan says an edit consisting of two codes describing two shoulder arthroscopy procedures will not be bypassed with a modifier.  

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 29826 is arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).  

We asked our coder 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 surgical shoulder arthroscopy (29826). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that based on the medical documentation submitted, the order in which these services were performed, CPT code 23412 is the more extensive procedure and CPT code 29826 does not meet any of the exceptions for unbundling services. Therefore, no separate reimbursement is allowed for 29826 RT 59.  

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical shoulder arthroscopy (29826) have not been met. Therefore, we decided that the Plan does not have to pay for the surgical shoulder arthroscopy (29826) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments and coinsurance for an eye exam and bevacizumab injection provided on August 10, 2021.  You asked the Plan to waive the copayments and coinsurance for the eye exam and injection. You say that you were charged two copayments for the same appointment. The Plan denied your request. The Plan says the correct copayments and coinsurance were 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 $25 copayment for each vision service.  Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs.  Service Allowed Amount Copayment/Coinsurance Eye Exam $90.92 $25 (Copayment) Computerized Imaging $41.40 $6.21 (less than 20% Coinsurance) Injection Administration $113.46 $25 (Copayment) Bevacizumab Drug $70.60 $14.12 (20% Coinsurance) Total:  $70.33  You have been asked to pay a $70.33 for the eye exam and injection. The eye exam falls within the Vision Care benefit category. The injection falls within the Medicare Part B Drugs 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 and coinsurance for an eye exam and bevacizumab injection provided on August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for an intraoperative electroencephalogram (EEG) (95955) provided June 29, 2021.  You asked the Plan to pay for an intraoperative EEG. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says this service was not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an intraoperative EEG. Our reviewer says that the intraoperative EEG was not medically necessary. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows neuromonitoring intraoperatively provided any significant decrease in neurological complications in one level anterior cervical discectomies and fusions. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intraoperative EEG have not been met. Therefore, we decided that the Plan does not have to pay for an intraoperative electroencephalogram (EEG) (95955) provided June 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on  August 2, 2021.  

You asked the Plan to waive the copayment for ambulance services. You say that you never received the services. The Plan denied your request. The Plan says the correct copayment was applied for the services. 

 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 each one-way Medicare-covered ground trip.     

You have been asked to pay a $250 copayment for ambulance services. Ambulance services falls 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 August 2, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on November 1, 2020, through November 30, 2020 and billed with Patient Driven Payment Model (PDPM) score KDXE1 for 30 days.  You asked the Plan to pay for the SNF services billed with PDPM score KDXE1 for 30 days. You say that you would like reconsideration because the documentation supports the PDPM score billed. The Plan denied your request. The Plan says the documentation does not include the required assessments to support the billed PDPM score.  The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code. Under the new Patient-Driven Payment Model (PDPM).  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM score KDXE1 for 30 days have not been met. Specifically, the documentation submitted does not include an assessment of the member's usual function. Without this assessment we are unable to validate the PDPM score billed. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on November 1, 2020, through November 30, 2020 and billed with Patient Driven Payment Model (PDPM) score KDXE1 for 30 days.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health services rendered on August 5, 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 covered.  The Plan must follow Medicare rules. The rules say that a clinical psychologist must have a referral and consult from the beneficiary's primary care physician.  We looked at the file and Medicare rules. There is no referral from the enrollee's primary care physician. 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 outpatient mental health services rendered on August 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copay for the lab services provided on August 30, 2021.  

You asked the Plan to waive the copay for the services provided. You say that you never had a charge in the past. The Plan denied your request. The Plan says the claim processed correctly.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copay for lab services in an outpatient hospital or freestanding laboratory.   

You have been asked to pay a $10 copay for the lab services provided. The services fall within the outpatient diagnostic tests 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 copay for the lab services provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay the cost of the resin-based composites provided on September 22, 2021.  You asked the Plan to pay the cost of the resin-based composites. You say that they did fillings instead of a cap which is the least expensive procedure. You say that they told you fillings were covered. The Plan denied your request. The Plan says the claim processed under the silver filling benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.     Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan is only required to pay the cost of a silver filling on back teeth. You are responsible up to the contracted fee of the resin-based filling. Therefore, we decided that the Plan does not have to pay the cost of the resin-based composites provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services provided to the enrollee from April 29, 2021, to June 15, 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 these services were not authorized.  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 psychotherapy services provided to the enrollee from April 29, 2021, to June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV therapy services coded as 80202, 96365, 96366 and 80048 provided on August 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the IV therapy. You say that you have enclosed medical records for your review to support medical necessity. Please review the enclosed documents and reprocess this claim based on your contractual agreement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the IV therapy services coded as 80202, 96365, 96366 and 80048 provided on August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sinus augmentation (D7951), therapeutic parenteral drugs (D9612), and unspecified preventive service (D1999) provided on July 20, 2021.  You asked the Plan to pay for the sinus augmentation, therapeutic parenteral drugs, and unspecified preventive service. You say that implants for teeth # 13 and 14 were approved by the plan. You also say you were advised you had $706.16 of your annual maximum benefit left. The Plan denied your request. The Plan says the annual maximum benefit has been met. The Plan also says implants are covered once every 5 years.  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 sinus augmentation, therapeutic parenteral drugs, and unspecified preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the sinus augmentation (D7951), therapeutic parenteral drugs (D9612), and unspecified preventive service (D1999) provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 20, 2021 by an out-of-network (OON) provider.  

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 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 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 the laboratory services provided on May 20, 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 coinsurance for a psychotherapy visit provided on April 14, 2021.  

You asked the Plan to waive the coinsurance for psychotherapy visit. You say that you are entitled to 80% coverage of all claims that you have filed. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.  

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 50% coinsurance for out-of-network outpatient mental health visit. The allowed amount of this claim is $146.67, resulting in a coinsurance amount of $73.34. Therefore, the Plan reimbursed you $73.33.  

You have been asked to pay 50% coinsurance for psychotherapy visit. Psychotherapy visit falls within the Outpatient Mental Health 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 coinsurance for a psychotherapy visit provided on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on July 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were not authorized.  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 file shows that a preventive exam and lab services were provided. 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 items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on July 21, 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 a telehealth service provided on September 7, 2021.  

You asked the Plan to waive the copayment for telehealth service. You say that the provider called you on the date of service. The Plan denied your request. The Plan says the appropriate 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $25 copayment for a Specialist's Telehealth services.     

The enrollee has been asked to pay a $25 copayment for a telehealth service. Telehealth services falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a telehealth service provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99212) provided on December 14, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that resubmitting the claim along with the supporting documents to support CPT code 99212 for reconsideration of payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the outpatient office visit (99212) provided on December 14, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the prostate surgery provided on August 19, 2021.  You asked the Plan to waive the copayment for the prostate surgery. You say that the Annual Notice of Changes states your copayment is $150 but your bill is $250. You say that this procedure was performed at the hospital's outpatient surgery center which is a distinct facility from the hospital and the copayment should be $150. The Plan denied your request. The Plan says the copayment applied 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 $250 copayment for each Medicare-covered outpatient hospital facility visit.    You have been asked to pay a $250 copayment for the prostate surgery. The prostate surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show this was outpatient surgery billed by the hospital. 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 prostate surgery provided on August 19, 2021.