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

We decided that the Plan does not have to waive the copayment for a medical eye exam provided on  
July 6, 2021. 
 
You asked the Plan to waive the copayment for the medical eye exam. The Plan denied your request. The Plan 
says a medical eye exam was performed on July 6, 2021 for a follow up of allergic dermatitis of the eyelid, and 
the documentation indicates that optic nerve imaging was also completed. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for Vision Care.  
 
You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam falls within the 
Vision 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 a medical eye exam 
provided on July 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER care provided on June 4, 2021, and June 5, 2021.
You asked the Plan to waive the copayment for the ER care. You say that x-rays are $35 each under your Plan and even if you have two (2), it should only be $70 not $90. The Plan denied your request. The Plan says the additional $90 emergency room copayment was approved since it applied incorrectly as you should have only been charged one ER copayment since this was one visit. The Plan states they remove one $90 copayment, and you are still responsible for the other $90 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received ER care provided on June 4, 2021, and June 5, 2021. You were asked
to pay a $90 copayment for the ER. Your 2021 EOC states that enrollees must pay a $90 copayment for each Medicare-covered emergency room visit. 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 ER care provided on June 4, 2021, and June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation care (CPT code G0378) provided from May 11, 2021, through May 14, 2021.
You asked the Plan to waive the copayment for the observation care. You say that you were never told it was an observation stay. The Plan denied your request. The Plan says they obtained documentation that you were made aware of your outpatient observation status at this provider on May 12, 2021.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the observation care from May 11, 2021, through May 14, 2021. You were asked to pay a $200 copayment for the observation care. Your 2021 EOC states that enrollees must pay a $200 copayment for each outpatient hospital observation 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 the observation care (CPT code G0378) provided from May 11, 2021, through May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 2, 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 referring provider 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 June 2, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for the canalith repositioning therapy service (procedure code 95992) you had on June 15, 2021.
You asked the Plan to waive the copayment for the canalith repositioning therapy service. You say that you were already charged a copayment for physical therapy on this date, and that copayment should include this service. The Plan denied your request. The Plan says that you were charged two separate copayments correctly. The Plan says that this service is considered a specialist service, so separate cost sharing applies.
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 says that you pay a $20 copayment per visit for physical therapy services. If the same service type is performed at the same session, only one copayment will apply.
We looked at your contract with the Plan. We also looked at the bill for these services. According to the bill, you had both a physical therapy visit and a canalith repositioning therapy service. Both services were performed by a physical therapist and both are considered outpatient rehabilitation services. A reasonable enrollee would expect that only one copayment would apply in this case, since all services were performed on the same day by the same provider type (i.e., a physical therapist.) It is not reasonable for the Plan to charge a separate copayment for the canalith repositioning therapy service based on this information. The contract does not spell out that a separate cost sharing amount would apply for this service by a physical therapist. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the canalith repositioning therapy service (procedure code 95992) you had on June 15, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Vectra DA testing services provided on January 18, 2021.
You asked the Plan to pay for the testing services. You say that you were not aware that the bloodwork was not covered. The Plan denied your request. The Plan says that there is limited evidence that the test will alter treatment or outcomes compared to standard tests.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the testing services by a contract provider. The file does not show that the Plan provided notice that the testing services would not be covered. Under Medicare rules, this means the testing services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the Vectra DA testing services provided on January 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-rays (D0230) provided on June 25, 2021.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you did not know these services were not covered under your plan. The Plan denied your request. The Plan says these services are 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220) and additional intraoral periapical x-rays (D0230) provided on June 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sleep study services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve sleep study services. You say that this care is medically necessary. The Plan denied your request. The Plan says there are multiple in-network providers available to provide the care you need.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve sleep study services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing received on June 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when received from an OON 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 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 genetic testing received on June 10, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided from April 14, 2021, through May 20, 2021.
You asked the Plan to pay for outpatient hospital services. You say that you thought these services would be covered. The Plan denied your request. The Plan says there is no documentation to support that the services were urgent or emergent or could not be provided within the provider network.
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 outpatient hospital services provided from April 14, 2021, through May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on June 21, 2021.
You asked the Plan to pay for the periodic oral evaluation. You say that the previous exam performed on May 3, 2021 was not completed as billed because you feel they did not do an exam. The Plan denied your request. The Plan says this service exceeds the coverage limits. The Plan also says that this procedure is limited to twice per calendar year.
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, oral examinations are limited to two per calendar year. The record shows that you received oral examinations on March 23, 2021, and May 3, 2021 and your oral examinations benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug (A9270) provided on May 19, 2021.
You asked the Plan to pay for the self-administered drug. You say that you did not receive any self-administered drugs. You say that you received a tetanus shot. You say that you received an antibiotic. You also
say that it should be covered under Part A. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.
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 drug (A9270) provided on May 19, 2021.
Benefits for the self-administered drug 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for a patient of extreme age (99100) provided on August 6, 2020.
You asked the Plan to pay for the anesthesia for a patient of extreme age. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this service is always bundled into payment for other services not specified.
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for coverage of the anesthesia for a patient of extreme age have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for a patient of extreme age (99100) provided on August 6, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to reduce your cost share amount for the Partial foot, shoe insert with longitudinal
arch, toe filler (L5000) provided on July 26, 2021.
You asked the Plan to reduce your cost share amount for the Partial foot, shoe insert with longitudinal arch, toe
filler. You say that you would like the Plan to assist in paying the remaining balance. The Plan denied your
request. The Plan says that you received a Partial foot, shoe insert with longitudinal arch, toe filler on the date
of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with
the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a 10% coinsurance for Durable medical equipment.
The Plan says you must pay a 20% coinsurance for the Partial foot, shoe insert with longitudinal arch, toe filler,
totaling $72.11. Based on the Plan contract, however, you cannot be asked to pay more than a 10% coinsurance
for the Partial foot, shoe insert with longitudinal arch, toe filler. The allowed amount for code L5000 is
$360.57. 10% of the allowed amount is $36.06. The Plan cannot ask you to pay more than your 10%
coinsurance for the durable medical equipment at issue. Therefore, we decided that the Plan has to reduce your
cost share amount for the Partial foot, shoe insert with longitudinal arch, toe filler (L5000) provided on July 26,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (CPT code 99214) provided the enrollee on April 2, 2021, by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 the office visit (CPT code 99214) provided the enrollee on April 2, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you feel you will not get the same care at a skilled nursing facility, and IRF services are necessary for your full recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your needs can be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found with your current medical stability, there is no need for physician supervision at least
three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. Based upon your current level o function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. You would benefit from physical and occupational therapy, but your needs can be safely met in an alternate and lower intensity setting. The requested IRF admission is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for negative pressure wound therapy (NPWT) services you received at an outpatient hospital facility from July 13, 2020, to August 12, 2020.
You asked the Plan to waive the copayments for the NPWT services. You say that these services were not in an operating room, they have been miscoded. You said that no one ever told you that when the type of wound vac was switched that you would be responsible for this cost sharing. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for each date of service ($319.91) is less than your copayment obligation, 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 $325 copayment for outpatient hospital services, including medical supplies.
You have been asked to pay a $325 copayment for the NPWT services. The NPWT services fall within the outpatient hospital services, including medical 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 copayments for negative pressure wound therapy (NPWT) services you received at an outpatient hospital facility from July 13, 2020, to August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an incisional biopsy of oral tissue (D7286) provided on December 1, 2020.
You asked the Plan to pay for an incisional biopsy of oral tissue. You say that you contacted the Plan, and you were told the biopsy would not be covered under your dental Plan. You also say that you were told it was a medical procedure and would like to be reimbursed for payment. The Plan denied your request. The Plan says the services were billed to your dental Plan and this is not a covered benefit. The Plan also says that you did contact the Plan prior to the date of service and the Plan stated they will not cover the service rendered under your dental 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an incisional biopsy of oral tissue (D7286) provided on December 1, 2020.