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

 We decided that the Plan does not have to pay for an echocardiography, transthoracic, real-time with image documentation provided on August 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an echocardiography, transthoracic, real-time with image documentation. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an echocardiography, transthoracic, real-time with image documentation provided on August 5, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (73100) provided July 23, 2021.  You asked the Plan to pay for the radiology services. You say that the radiology services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 73100 is a column II code to column I code 73110. 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 radiology services (73100) provided July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient surgery provided on August 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient surgery. You say that it is ultimately the enrollees's responsibility to  verify if the provider is participating. The Plan denied your request. The Plan says no prior authorization was obtained.   Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient surgery provided on August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the office visit (99213), the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610), the x-ray exam of the knee (73564), and the triamcinolone acetonide injection (J3304) rendered by the out-of-network (OON) provider on August 17, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that 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 in cases involving emergencies, out of area urgent care, pre-approved care, and for services that are covered benefits and are medically necessary.  The provider in this case is not a network provider with the Plan. However, the Plan contract states that as a member of the plan, an enrollee can choose to receive care from out-of-network providers. The enrollee does not need to get a referral or prior authorization when they obtain care from out-of-network providers. Therefore, we decided that the Plan has to pay for the office visit (99213), the arthrocentesis, aspiration and/or injection, of a major joint or bursa (20610), the x-ray exam of the knee (73564), and the triamcinolone acetonide injection (J3304) rendered by the out-of-network (OON) provider on August 17, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740) and core build up (D250) provided on September 2, 2021.  You asked the Plan to pay for the dental services. You say that this bill is a financial hardship for you. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says there is an annual maximum of $1,000. The Plan also says that the annual maximum benefit has 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit. Additionally, the record shows that the annual maximum benefit has been exhausted. The record shows that the Plan paid $79.83 for dental services received on January 12, 2021, $64.36 for services received on July 20, 2021, $351.27 for services received on July 27, 2021, and $504.54 for services received on September 2, 2021. $79.83 + $64.36 + $351.27 + $504.54 = $1,000. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core build up (D250) provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance the wrist brace provided by an out-of-network provider on September 17, 2021.  You asked the Plan to waive the coinsurance the wrist brace. You say that the wrist brace did not fit, and you were told you would not be charged. The Plan denied your request. The Plan says you have been asked to pay 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 20%  for of the cost for Medicare-covered prosthetic devices and medical supplies related to prosthetic, splints, and other devices.   You have been asked to pay $39.60 which is 20% of the allowed amount for the wrist brace. The allowed amount is $198. ($198 x 20% = $39.60). The wrist brace falls within the "Prosthetic devices and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance the wrist brace provided by an out-of-network provider on September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on August 13, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you did not give yourself any kind of medication. The Plan denied your request. The Plan says self-administered drugs are not covered services under your plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on August 13, 2021.   Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for oxygen equipment provided from June 20, 2021, to October 21, 2021.  You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you do not know why the bill increased after switching plans. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment (DME) and supplies, including oxygen equipment.   Item Allowed Amount 20% Coinsurance Oxygen Concentrator (E1390) - June 20, 2021 $103.26 $20.65 Portable Oxygen Machine (E1392) - June 21, 2021 $63.00 $12.60 Oxygen Concentrator (E1390) - July 20, 2021 $103.26 $20.65 Portable Oxygen Machine (E1392) - July 21, 2021 $63.00 $12.60 Oxygen Concentrator (E1390) - August 20, 2021 $103.26 $20.65 Portable Oxygen Machine (E1392) - August 21, 2021 $63.00 $12.60 Oxygen Concentrator (E1390) - September 20, 2021 $103.26 $20.65 Portable Oxygen Machine (E1392) - September 21, 2021 $63.00 $12.60 Total:  $133.00  You have been asked to pay $133.00, which is 20% of the allowed amount for the oxygen equipment. The oxygen equipment falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for oxygen equipment provided from June 20, 2021, to October 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the office visit (99213) and the laboratory service (83861) provided on October 26, 2021.  You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). Additionally, you must pay a $35 copayment for each  in-person specialist visit. If you receive other services during an office visit, the deductible, and other cost sharing may apply according to the benefit specific category in the medical benefits chart.   You have been asked to pay $45 ($35 + $10) for the specialist office visit and the diagnostic laboratory service 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 copayments for the office visit (99213) and the laboratory service (83861) provided on October 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the colonoscopy, flexible; with biopsy, single or multiple (45380) provided on October 12, 2021.  You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the service 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 when a screening colonoscopy or sigmoidoscopy becomes a diagnostic procedure (results in a biopsy or removal of a lesion or growth), then outpatient surgery cost sharing and/or deductible, as applicable, may apply. Additionally, your annual deductible is $750.   You have been asked to pay $198 for the diagnostic colonoscopy provided. You have not previously met the annual deductible. Until you have paid the deductible amount, you must pay the full cost of your covered services. The Plan allowed amount for this service is $198. 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 share for the colonoscopy, flexible; with biopsy, single or multiple (45380) provided on October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the injection(s), of a diagnostic or therapeutic substance, not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) provided on October 22, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $200 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility.   You have been asked to pay a $200 copayment for the outpatient surgery provided at an ambulatory surgical center. 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 injection(s), of a diagnostic or therapeutic substance, not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral; with imaging guidance (62323) provided on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on October 28, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on  October 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (85060) provided September 9, 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 claim was not billed with a valid place of service.  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 85060 is not supported in the medical record. Specifically, this code has a professional component / technical component indicator of 8 and is not separately payable for the place of service billed (22). 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 (85060) provided September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-network provider on May 11, 2021.  You asked the Plan to pay for a limited oral evaluation (D0140). You say that you were told that this would be covered. The Plan denied your request. The Plan says a limited oral evaluation is not a covered 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, a limited oral evaluation is not among those covered under this benefit. The intraoral radiographic image (D0220), and endodontic therapy (D3330) that was provided was processed with a 50% coinsurance. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by an out-of-network provider on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 3, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that the injections are necessary but you can no longer afford the copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist services.   You have been asked to pay a $40 copayment for a specialist visit. A specialist 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 visit provided on February 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (70450) provided September 24, 2021.  You asked the Plan to pay for the radiology services. You say that the radiology services were medically necessary. The Plan denied your request. The Plan says the billed code has a bundled relationship with another code 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, 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 radiology services (70450) provided September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on September 28, 2021.  You asked the Plan to waive the copayment for laboratory services. You say that you have never been charged for laboratory services in the past and want to know if this bill is an error. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for laboratory services provided in a primary care provider's office, specialists office, or freestanding laboratory, a $30 copayment when provided in an urgent care center and a $40 copayment when provided at an outpatient hospital facility.   The record shows that you received laboratory services at an outpatient hospital facility on September 28, 2021. Therefore, you are responsible to pay the $40 copayment.  You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on September 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on August 19, 2021.  You asked the Plan to reimburse you an additional amount for the eyeglasses. You say that you should be reimbursed more for the eyeglasses as the copayment should be $30.00 like an in-network provider as you did not know the provider was out-of-network and you feel they were not honest about the costs for the eyeglasses. The Plan denied your request. The Plan says the Plan processed the claim correctly with the out-of-network $60 copayment for one pair of Medicare-covered standard eyeglasses.  Medicare covers one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an intraocular lens implant. The Plan contract says eyeglasses after cataract surgery are covered out-of-network with a $60 copayment.  We looked at the file, the Medicare rules and the Plan's rules. The file shows that the Plan contract says that eyeglasses after cataract surgery are covered out-of-network with a $60 copayment. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on August 19, 2021.