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

We decided that the Plan does not have to pay for the cytopathology rendered on November 11, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.

The provider submitted a claim for procedure codes 88112 (cytopathology) and 88173 (cytopathology,
interpretation and report). Code 88112 is a column II code with a modifier indicator of 1 when billed with
column I code 88173. Code 88112 was not billed with an appropriate modifier to allow for separate payment.

Therefore, we decided that the Plan does not have to pay for the cytopathology rendered on November 11,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 24, 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 billed are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on November 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room service (99283) provided on April 23, 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 $50 copayment for Medicare-covered emergency services. 

You have been asked to pay a $50 copayment for the Medicare-covered emergency room 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 copayment for the emergency room service (99283) provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on July 13, 2021 and July 16, 
2021. 
 
You asked the Plan to pay for the vision services. You say that you were told using an out-of-network provider 
shouldn't be a problem. You say that received a better deal from the out-of-network they should be part of the 
network. The Plan denied your request. The Plan says out-of-network services are not covered. 

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when they are received from a network provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Specifically, the services were received from an out-of-
network provider. Therefore, we decided that the Plan does not have to pay for the vision services provided on 
July 13, 2021 and July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the oral exam (D0120), prophylaxis 
(D1110), and fluoride varnish (D1206) provided on June 10, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that you have a $0 copayment 
for preventive dental services received in and out of network. You also say that the plan did not pay 100% for 
the preventive dental services that you received. The Plan denied your request. The Plan says the claim was 
processed correctly. The Plan also says out of network providers may bill you for any amount greater than what 
the plan pays. 
 
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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Specifically, the file shows that the provider in this case is 
out of network. The Evidence of Coverage clearly states that if you choose to see an out of network dentist, you 
might be billed for any amount greater than what the plan pays, even for services listed as $0 copayment. 
Therefore, we decided that the Plan does not have to pay an additional amount for the oral exam (D0120), 
prophylaxis (D1110), and fluoride varnish (D1206) provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the 
out-of-network (OON) provider on July 7, 2021 and July 8, 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 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 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 services. Therefore, we decided that the 
Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) 
provider on July 7, 2021 and July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures received from a chiropractor from June 8, 2021 to June 21, 2021.

You asked the Plan to pay for the therapeutic procedures. You say that you would like this denial to be reconsidered. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures received from a chiropractor from June 8, 2021 to June 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Ertapenem injections (J1335 x 2) provided from May 21, 2021, through June 29, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has 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 20% coinsurance for each Medicare-covered Part B drug for home infusion therapy. 

You have been asked to pay 479.84 (Plan allowed amount of $2,399.20 x 20% coinsurance) for the Medicare-covered Part B drugs provided for home infusion therapy.

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 the Ertapenem injections (J1335 x 2) provided from
May 21, 2021, through June 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy service (90832) rendered by the out-of-
network (OON) provider on May 5, 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 psychotherapy service (90832) rendered by the out-of-network (OON) provider on 
May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials rendered on March 6, 
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 procedure code 99072 is not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and 
clinical staff time over and above those usually included in an office visit or other non-facility service(s), when 
performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious 
disease) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan 
does not have to pay for the additional supplies and materials rendered on March 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 6, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you were diagnosed with T-Cell Lymphoma in 2007. Chemo and Radiation to the mouth are a part of the treatment. The dental visits to an oral surgeon and periodontist are due to your cancer and not normal dental decay or correction. The Plan denied your request. The Plan says there is no coverage for limited oral evaluation problem focused services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 6, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on April 22, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that because of the initial provider's actions, you were forced to see another dental provider. You also say that you believe this exam should be covered. The Plan denied your request. The Plan says the limitation for this service has been met for the benefit 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, you are limited to 2 problem focused exams every calendar year. The record shows that you received problem focused limited oral evaluations (D0140) on March 9, 2021, and April 14, 2021 and your problem focused exams benefit has been exhausted.
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation
(D0140) provided on April 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an ultrasound of upper or lower extremity
arteries (93922) and a testing of autonomic nervous system function (95923) provided on April 13, 2021.

You asked the Plan to waive the cost-sharing for an ultrasound of upper or lower extremity arteries and a
testing of autonomic nervous system function. You say that you dispute the applied cost-sharing. The Plan
denied your request. The Plan says the correct cost-sharing 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 $155
copayment for Medicare-covered radiological diagnostic services, not including x-rays, and a $30 copayment
for Medicare-covered non-radiological diagnostic services.

You have been asked to pay a $81.39 copayment for an ultrasound of upper or lower extremity arteries. You
have also been asked to pay a $30 copayment for a testing of autonomic nervous system function. An
ultrasound of upper or lower extremity arteries, and a testing of autonomic nervous system function, fall within
the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you
have been asked to pay less than or equal to the full 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-sharing for an ultrasound of upper or lower extremity arteries (93922)
and a testing of autonomic nervous system function (95923) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on April 28, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided on April 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided April 23, 2021.
You asked the Plan to pay for the eye refraction. You say that a plan representative said the service would be covered. The Plan denied your request. The Plan says you do not have routine vision benefits and this service is not covered under your medical benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided April 23, 2021.
Your complaint about potentially being provided misinformation by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound interpretation provided on June 11, 2021, billed with code 76700.
You asked the Plan to pay for the abdominal ultrasound interpretation. You say that this should be paid since the enrollee had multiple exams on the same date. The Plan denied your request. The Plan says the provider billed for 93976 on the same date of service. There was not required NCCI modifier used for 76700.
The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only the Column 1 code is payable unless a clinically appropriate modifier is used.
We looked at the file and Medicare rules. Code 76700 is a Column 2 code in relation to 93976, which was also billed by the provider for this date of service. No clinically appropriate NCCI modifier was used to justify bypassing the edit. Based on this information, we decided that Medicare rules for coverage of the abdominal ultrasound interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound interpretation provided on June 11, 2021, billed with code 76700.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the cost-sharing for laboratory testing and outpatient surgery provided
from April 20, 2021, to May 17, 2021.
You asked the Plan to waive the cost-sharing for lab tests and outpatient surgery. You say that you met your
out-of-pocket maximum for 2021 and should not have to pay additional cost-sharing. The Plan denied your
request. The Plan says that the cost-sharing amounts you are being charged are correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. You say that you met the maximum out-of-pocket amount for 2021 and should
not be charged additional cost-sharing. The Plan did not submit a summary of the cost-sharing applied to your
maximum out-of-pocket amounts in the original case file. We requested this information, and the Plan did
submit a summary of cost-sharing applied to your maximum out-of-pocket amounts. However, the summary
the Plan submitted contains information that is directly contradictory to the explanations of benefits (EOBs) the
Plan submitted detailing the cost-sharing you are being asked to pay. Therefore, it cannot be determined that
the summary of cost-sharing amounts applied to your maximum out-of-pocket amounts in 2021 contains true or
accurate information. Therefore, the Plan has not shown that your maximum out-of-pocket amount had not
been met at the time these claims were processed. Therefore, the Plan has not shown that its decision to ask you
to pay these cost-sharing amounts is correct or justified according to Medicare rules and your contract with the
Plan. Therefore, we decided that the Plan has to waive the cost-sharing for laboratory testing and outpatient
surgery provided from April 20, 2021, to May 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve wound care services to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 wound care 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 laboratory services rendered on September 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing setting and
should have been billed with POS code 31. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 21, 2020.