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

We decided that the Plan has to waive the copayment for diagnostic mammography, including CAD when performed; unilateral (77065) diagnostic digital breast tomosynthesis (G0279) provided August 16, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you truly do not feel there would have been a need for this follow up if the technician had positioned you correctly the first time. You are filing a grievance as you do not feel you should have to pay for their mistake. The Plan denied your request. The Plan says that this claim was processed with the correct copayment applied per the Evidence of Coverage
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 $75 copayment for diagnostic mammography in an outpatient hospital for Outpatient diagnostic tests and therapeutic services and supplies. The Plan says you must pay $95 ($75 + $20) The plan applied $75 copayment towards CPT code 77065 and $175 copayment towards CPT code G0279. For CPT code G0279 the allowed amount was $20 which applied towards the copayment amount. Based on the Plan contract, however, you cannot be asked to pay more than $75 copayment for diagnostic mammography. The tomosynthesis is a part of the mammogram procedure. Therefore, we decided that the Plan has to waive the copayment for diagnostic mammography, including CAD when performed; unilateral (77065) diagnostic digital breast tomosynthesis (G0279) provided August 16, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of the power wheelchair for the enrollee.
You asked the Plan to pre-approve the replacement. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare criteria are not met for a replacement power wheelchair as the enrollee currently has a power wheelchair that is less than five years old.
The Plan follows Medicare rules. Medicare rules say that durable medical equipment replacements cannot be covered before the reasonable useful lifetime is up, unless there is a case of loss or irreparable damage. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 the replacement. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the requested E2300 does not serve a primary medical need per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not reveal that there is irreparable wear or damage to his current wheelchair that requires a new power wheelchair. The enrollee's current wheelchair is less than five years old. Additionally, the request for a power wheelchair that can be retrofitted to a seat elevator exceeds the enrollee's medical needs, and is not medically reasonable or 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 the replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement of the power wheelchair for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services provided from September 14, 2021, to September 15, 2021.
You asked the Plan to waive the copay for the services provided. You say that you were taken to the emergency room against your will. 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 $90 copay for emergency care. You have been asked to pay a $90 copay for the services provided. The services fall within the emergency 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 copay for the emergency room services provided from September 14, 2021, to September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection services provided from January
20, 2021, and February 10, 2021.
You asked the Plan to waive the cost share for the services provided. You say that you were told the service
would be covered. The Plan denied your request. The Plan says you are responsible for the coinsurance.
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 Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the services provided. The services fall within the Medicare
Part B prescription 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 cost share for the injection
services provided from January 20, 2021, and February 10, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for group psychotherapy provided from July 1, 2021, through August 26, 2021.
You asked the Plan to waive the copayment for group psychotherapy. You say that you were billed copayments for virtual visits that should have no copayment. The Plan denied your request. The Plan says the copayments 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 $100 copayment for mental health services from an in-network outpatient hospital.
You have been asked to pay $92.60, which is less than the standard $100 copayment for each group psychotherapy visit. Group psychotherapy 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 copayment for group psychotherapy provided from July 1, 2021, through August 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an echocardiogram (EKG) provided on July 19, 2021.
You asked the Plan to waive the deductible for the EKG. You say that the provider's office informed you of only the $30 copayment. The Plan denied your request. The Plan says the correct amount was applied to your deductible.
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 there is $500 deductible which applies to certain items and services. The item or service you asked the Plan to waive the deductible for falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not been met at the time the EKG was received on July 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an echocardiogram (EKG) provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on August 31, 2021.
You asked the Plan to waive the copayment for an office visit. You say that you do not mind paying the $10 lab copayment but do not want to pay for the office visit. 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 $5 copayment for visits with a primary care physician. You have been asked to pay a $5 copayment for an office visit. An office 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 an office visit provided on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81302, 81330, 81332, 81345, 81404, 81405, 81406, 81407, 81408, and 81479 provided on December 14, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81302, 81330, 81332, 81345, 81404, 81405, 81406, 81407, 81408, and 81479 are not supported in the medical record. Specifically, the documentation shows that molecular pathology testing was performed. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel.
Review of the file shows that one CPT code was not submitted for the services rendered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81302, 81330, 81332, 81345, 81404, 81405, 81406, 81407, 81408, and 81479 provided on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an MRI scan of a joint of the lower extremity (73721), an MRI scan of the spine (72148), and an ultrasound of extracranial arteries (93880) provided on June 22 to July 1, 2021.
You asked the Plan to waive the copayments for an MRI scan of a lower-extremity joint, an MRI scan of the spine, and an ultrasound of extracranial arteries. You say that the charges assessed are out of the norm. The Plan denied your request. The Plan says the correct copayments 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 $115 copayment for Medicare-covered radiological diagnostic services, not including X-rays.
You have been asked to pay a $115 copayment per date of service for an MRI scan of a lower-extremity joint, an MRI scan of the spine, and an ultrasound of extracranial arteries. An MRI scan of a lower-extremity joint, an MRI scan of the spine, and an ultrasound of extracranial arteries 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 copayments for an MRI scan of a joint of the lower extremity (73721), an MRI scan of the spine (72148), and an ultrasound of extracranial arteries (93880) provided on June 22 to July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular risk analysis (81407, 81408, 81479, 81439, 81291, 91401, 81403, 81404, 81405, 81406) provided on July 30, 2020.
You asked the Plan to pay for a hereditary cardiovascular risk analysis. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular risk analysis have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular risk analysis (81407, 81408, 81479, 81439, 81291, 91401, 81403, 81404, 81405, 81406) provided on July 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids that you purchased from an out-of-network provider on May 7, 2021.
You asked the Plan to pay for the out-of-network hearing aids. You say that you called the Plan prior to buying the hearing aids to confirm you were covered. The Plan denied your request. The Plan says while hearing aids are a covered benefit under your plan, you must use a plan provider in order for them to be covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when received from a network provider. You did not purchase these hearing aids from a network provider. Therefore, we decided that the Plan does not have to pay for hearing aids that you purchased from an out-of-network provider on May 7, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services (17313, 15271) provided August 10, 2021 to August 17, 2021.
You asked the Plan to waive the copayment for the surgical services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct 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 $200 copayment for Outpatient Surgery. You have been asked to pay a $200 copayment for date of service August 10, 2021 and the Medicare allowable amount of $151.88 for date of service August 17, 2021. the surgical services fall within the Outpatient Surgery 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 surgical services (17313, 15271) provided August 10, 2021 to August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Protext injection provided on July 22, 2021, billed with 8 units of Q4246.
You asked the Plan to pay for the number of units billed. You say that this is supported by the record. The Plan denied your request. The Plan says the operative report does not show 8 cc's of Protext were injected.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 8 units of CPT code Q4246 are not supported in the medical record. Each unit is 1 cc of the agent. The record shows that 2mL (which are equal to cc's) were injected. The medical record only supports 2 units of CPT code Q4246.
Based on this information, we decided that Medicare rules for coverage of the number of units billed have not been met. Therefore, we decided that the Plan does not have to pay for the Protext injection provided on July 22, 2021, billed with 8 units of Q4246
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on October 6, 2021.
You asked the Plan to pay for the resin-based composite. You say that you were not aware of this limitation prior to the service. You say that you were not informed of the total cost insurance would not cover and you could have received a crown which would have been covered. The Plan denied your request. The Plan says reimbursement has already been issued for two fillings.
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, you also have a maximum benefit of two fillings per calendar year. The Plan paid for two resin-based composites provided on March 17, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on October 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Paramedic intercept provided on August 29, 2021.
You asked the Plan to pay for Paramedic intercept. You say that the enrollee had no control over who was sent to transport him to the hospital. You say that you could not take him in your car because of his rectal bleeding. The Plan denied your request. The Plan says Paramedic intercept services provided to areas other than rural New York are non-covered.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for Paramedic intercept provided on August 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on July 12, 2021.
You asked the Plan to waive the deductible for an office visit. You say that you should owe $0 for office visits. 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. Your contract with the Plan says that there is a $198 deductible which applies to physician/practitioner services, including doctor's office visits. You had an office visit on July 12, 2021. The record shows that you had only paid $92.02 toward the $198 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $63.78. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on July 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power mobility device provided on July 13, 2021.
You asked the Plan to pay for the provided service. You say that you already paid for it out of pocket. The Plan
denied your request. The Plan says durable medical equipment must be obtained from a Medicare certified
provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says you receive your care from a provider who is eligible to provider services under Original Medicare.
The provider in this case is not a network provider with the Plan. The provider is not eligible to provider
services under Original Medicare. 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 power mobility device
provided on July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on May 25, 2021, billed with code 81455
You asked the Plan to pay for the F1Heme panel. You say that this testing was validated by the Centers for Medicare and Medicaid Service and cannot be denied by a Medicare Advantage plan. The Plan denied your request. The Plan says this code is for testing that is unlikely to impact therapeutic decision-making.
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with AML for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare.
We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes
analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for
51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the
entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have
to pay for the FoundationOne Heme (F1Heme) genetic testing panel provided on May 25, 2021, billed with
code 81455