Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regenerations (D4266), surgical extractions
(D7210), and bone replacement grafts for ridge preservations (D7953) provided on October 18, 2021.
You asked the Plan to pay for the guided tissue regenerations, surgical extractions, and bone replacement
grafts. You say that the treating provider is listed as in-network. You also say that your billing should be
adjusted to reflect a refund. 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
guided tissue regenerations (D4266), surgical extractions (D7210), and bone replacement grafts for ridge
preservations (D7953) provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a laboratory test provided on October 18, 2021.  You asked the Plan to waive the copayment for the laboratory test. You say that you never had a copayment for this service and prior lab test were billed different. The Plan denied your request. The Plan says plan benefits change year to year and determined prior billing was billed as inpatient. the copayment applied for this service was correct.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $6 copayment for lab services drawn at a physician's office and sent to an independent lab for processing.     You have been asked to pay a $6 copayment for a laboratory test. Laboratory test falls 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 a laboratory test provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services provided between January 4, 2021, through June
21, 2021.
You asked the Plan to pay for the medical services. You say that you would like the cost share waived for the
services you received. The Plan denied your request. The Plan says that you must submit these claims to
Medicaid.
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 nothing ($0) for covered medical services.
The Plan has charged you a cost share that totals $219.91 for the medical services provided between January 4,
2021, through June 21, 2021. Based on the Plan contract, however, you cannot be asked to pay more than $0
for the medical services. Therefore, we decided that the Plan has to pay for the medical services provided
between January 4, 2021, through June 21, 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 pay for an office visit (99213) provided on June 9, 2021, by an out-
of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your
request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on June 9, 2021,
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on September 13, 2021.
You asked the Plan to waive the coinsurance for the laboratory services. You say that the plan told the enrollee that the services would be provided by an In-Network provider. The Plan denied your request. The Plan says the proper coinsurance was applied for an Out-of-Network provider.
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 45% coinsurance for an Out-of-Network Medicare-covered lab services. The total amount allowed was $39.55 with the coinsurance being $17.80 ($39.95 total amount x 45% coinsurance).
The enrollee has been asked to pay a 45% coinsurance for laboratory services. Laboratory services falls within the Out-of-Network Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation 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 laboratory services provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81162) provided May 25, 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 these services were for screening purposes and are non-covered.
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 test at issue in this appeal, genetic testing, 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 lab
services (81162) provided May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the thigh muscle repair provided on July 15, 2021.

You asked the Plan to reduce the copayment for the thigh muscle repair. You say that outpatient surgery is $150 per your policy, and you have no idea how they got $275. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.

You have been asked to pay a $275 copayment for the thigh muscle repair. The thigh muscle repair falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show the thigh muscle repair was provided by the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the thigh muscle repair provided on July 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit on September 11,
2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that any copayment should
be waived for the visit. The Plan denied your request. The Plan says the proper 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 $90
copayment for Medicare-covered emergency room visits.
You have been asked to pay a $90 copayment for the emergency room visit. Emergency room visit falls 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 copayment for an emergency room
visit on September 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies coded as 99072 provided on April 30,
2021.
You asked the Plan to pay for the additional supplies. You say that you would like this claim reprocessed based
on the medical documentation. The Plan denied your request. The Plan says separate payment is not made for
this service per Medicare coding regulations.
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 99072 is 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.
We looked at the file and Medicare rules. In this case, code 99072 has a Status Code of "B" under the
Physician Fee Schedule. This Status Code indicates that payment for covered services are always bundled into
payment for other services not specified. Based on this information, we decided that Medicare rules for
coverage of the additional supplies have not been met. Therefore, we decided that the Plan does not have to pay
for the additional supplies coded as 99072 provided on April 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), removal of residual tooth 
roots (D7250), and inhalation of nitrous oxide (D9230) provided on September 8, 2021.

You asked the Plan to pay for the dental services. You say that you were told you could go to any dentist. You 
say that you were not told that the doctor needed to accept Medicare because you had to pay for the
services upfront anyway and wait for reimbursement. You also say that this claim was denied incorrectly. The 
Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says 
that payment cannot be made to providers that have opted out of Medicare.

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, dental services performed by a 
provider that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pay for the surgical extraction (D7210), removal of residual tooth roots (D7250), 
and inhalation of nitrous oxide (D9230) provided on September 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from June 7, 2021, to June 24,
2021 and billed with diagnosis related group (DRG) code 094.
You asked the Plan to pay for the inpatient hospital services billed with DRG 094. You say that this claim was
underpaid due to the payer paid on DRG 493 instead of the billed DRG 094. You also say that you would like
this claim to be reprocessed and payment to be remitted for the additional amount due. The Plan denied your
request. The Plan says that this claim was paid accordingly per the DRG rates.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide the medical records for this case. Without this
information we cannot determine that the Plan's coverage rules support the denial of payment in this case.
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that
the Plan has to pay for the inpatient hospital services provided from June 7, 2021, to June 24, 2021 and billed
with diagnosis related group (DRG) code 094.
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 waive the coinsurance for an out-of-network (OON) office visit 
provided on September 16, 2021. We also decided that the Plan does not have to waive the coinsurance for an 
out-of-network (OON) wellness exam provided on September 16, 2021.

You asked the Plan to waive the coinsurance for the office visit and wellness exam. You say that you were not 
aware that the provider was out-of-network. 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 45% 
coinsurance for each out-of-network primary care provider office visit.

Your contract with the Plan also clearly says that you must pay a 45% coinsurance for each out-of-network 
annual wellness visit.
 
You have been asked to pay $57.71, which is 45% of the allowed amount for the office visit ($128.24 allowed 
amount x 45% coinsurance = $57.71). The office visit falls within the Physician/Practitioner Services, 
Including Doctor's Office Visits benefit category. You have also been asked to pay $56.60, which is 45% of the 
allowed amount for the wellness exam ($125.78 allowed amount x 45% coinsurance = $56.60). The wellness 
exam falls within the Annual Wellness Visit benefit category. The total for the visit is $114.31. 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 an out-of-network (OON) office visit provided on September 16, 
2021. We also decided that the Plan does not have to waive the coinsurance for an out-of-network (OON) 
wellness exam provided on September 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance ground transportation (A0425, A0427) rendered on August 6, 2021

You asked the Plan to waive the copayment for ambulance ground transportation. You say that you did not choose to go to the hospital. The Plan denied your request. The Plan says you were charged 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 a $100 copayment for ambulance services.

You have been asked to pay a $100 copayment for ambulance ground transportation. Ambulance ground transportation falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance ground transportation (A0425, A0427) rendered on August 6, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment purchased on January 8, 
2021, through February 20, 2021.

You asked the Plan to pay for the durable medical equipment. You say that the items should be covered. The 
Plan denied your request. The Plan says you obtained durable medical equipment from a provider who is not 
certified with Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
purchased on January 8, 2021, through February 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the perfusionist services (86891, 99190, P9022) provided on 
June 22, 2021.

You asked the Plan to pay for the perfusionist services. You say that you would like this claim reprocessed 
based on the medical documentation. The Plan denied your request. The Plan says these services must be billed 
by the facility.

The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to 
inpatients must be furnished directly by the hospital or billed through the hospital under arrangements

We looked at the file and Medicare rules. In this case, the documentation shows that the enrollee was inpatient 
during the dates of service. These services must be paid directly through the facility. Based on this information, 
we decided that Medicare rules for coverage of the perfusionist services have not been met. Therefore, we 
decided that the Plan does not have to pay for the perfusionist services (86891, 99190, P9022) provided on 
June 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on October 22, 2021.

You asked the Plan to pay for the bitewing x-rays. The Plan denied your request. The Plan says this service 
exceeds the maximum allowed per period.

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, bitewing x-rays are limited to one 
procedure per plan year. The record shows that you received bitewing x-rays (D0274) on January 27, 2021 and 
your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for
the bitewing x-rays (D0274) provided on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast surgery services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says
cosmetic services are not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The file shows that a left breast implant removal procedure was requested. 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 requested services. Our physician reviewer found that a plastic surgery
consultation documented the left breast as mildly firm and non-tender. The documentation does not support
that the left breast has a broken or failed implant, infection, implant extrusion, siliconoma or granuloma,
interference with a diagnosis of breast cancer, or painful capsular contracture with disfigurement. The
documentation does not support that removal of the left breast is medically reasonable and necessary for the
enrollee in this case.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve breast surgery services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on August 6, 2021.
You asked the Plan to pay for the services provided. You say that the place of service is correct. The Plan denied your request. The Plan says the claim was billed with an inappropriate 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 code.
We looked at the file and the rules. The claim information provided shows that the enrollee was an inpatient at the time the services were provided. The anesthesia services at issue were billed with an outpatient place of service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on August 6, 2021