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

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on July 12, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you thought this was a routine visit and you were not told it would be a medical visit. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for medical eye exams. You have been asked to pay a $35 copayment for the medical eye exam. We looked at the medical records from this visit to determine what type of visit you had. According to the records, you were seen for a diabetic ocular evaluation with complaints of blurred vision. Your diabetic symptoms were reviewed as were your diabetic lab values. These are services are medical in nature and are not part of a routine exam. That is why this eye exam falls within the medical eye exams 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 the medical eye exam you had on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 8, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 

We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show that 22 or more drug classes were tested on the date of service in question. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast magnetic resonance imaging (MRI) you had on June 21, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you have had three prior MRIs and you have never been billed for them before. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment for MRIs. You have been asked to pay a $250 copayment for the MRI. 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 breast magnetic resonance imaging (MRI) you had on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by a chiropractor on May 26, 2021.
You asked the Plan to pay for the office visit. 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.
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 office visit provided by a chiropractor on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services provided to the enrollee on June 17, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an incorrect place of service was reported.
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 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter." We find that CPT code 99214 is not supported in the medical record. Specifically, this telehealth service was billed with a place of service 22, which would indicate an outpatient hospital setting. This is incorrect. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services provided to the enrollee on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88312) rendered by the out-of-
network (OON) provider on May 28, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the laboratory service (88312) rendered by the out-of-network (OON) provider on
May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on March 31, 2021.

You asked the Plan to waive the copayment for an x-ray. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment applied 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 $150 copayment for x-rays performed in an in-network Outpatient Hospital Facility.

You have been asked to pay $74.99 for an in-network x-ray, which is less than your $150 copayment. X-rays fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray provided on March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5211) and mandibular partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5212) provided February 24, 2021.
You asked the Plan to pay for the upper and lower partial dentures. You say that you were told the services would be covered. The Plan denied your request. The Plan says you previously had an approval for the services under a different plan but there is no coverage under your current plan.
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
maxillary partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5211) and mandibular partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5212) provided February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81206, 81210, 81235, 81272,
81275, 81276, 81301, 81311, and 81321 provided on February 22, 2021.
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 81206, 81210, 81235, 81272, 81275, 81276, 81301, 81311, and 81321 are not
supported in the medical record. Specifically, the services rendered should be billed with code 81479. In
addition, the DEX-Z code should be entered adjacent in the comment/narrative field. Review of the file shows
that the services rendered were billed as unbundled services and not with one CPT code. 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 81206, 81210,
81235, 81272, 81275, 81276, 81301, 81311, and 81321 provided on February 22, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services received on May 15, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says they have been unable to retrieve an Explanation of Benefits from the primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has unsuccessfully attempted to request the Explanation of Benefits from the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for imaging services received on May 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (99601, 99602) provided on March 23 and March 24, 2021.
You asked the Plan to pay for home infusion services. You say that the services at issue are Medicare-covered. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Codes 99601 and 99602 have a status indicator of "I" on the Physician Fee Schedule. This means that they are "invalid for Medicare billing purposes." Based on this information, we decided that Medicare rules for coverage of home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (99601, 99602) provided on March 23 and March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care services you received on May 28, 2021.
You asked the Plan to reduce the copayment for the urgent care services. You say that your primary care provider was not available, so you were sent to urgent care. You said that you should only have to pay the $10 primary care copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $15 copayment for urgent care services not provided by your primary care provider. You have been asked to pay a $15 copayment for the urgent care services. The services you received fall within the urgent care services not provided by your primary care provider benefit category. This copayment applies regardless of the reason why you used this specific provider. 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 urgent care services you received on May 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the intravenous (IV) drug therapy received on July 6, 2021, and the occupational therapy service provided on July 5, 2021.
You asked the Plan to waive the cost sharing for the IV drug therapy and the occupational therapy service. You say that you were told that this claim had been paid. You said that the enrollee was suffering from a reaction to a cat scratch and required these services. The Plan denied your request. The Plan says the enrollee was charged these cost sharing amounts correctly. The Plan has confirmed that the enrollee is only responsible for $80.70.
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 enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B drugs and a $40 copayment for occupational therapy services.
The enrollee has been asked to pay 20% coinsurance for the IV drug therapy and a $40 copayment for the occupational therapy service. The IV drug therapy falls within the Medicare Part B drugs 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 the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the intravenous (IV) drug therapy received on July 6, 2021, and the occupational therapy service provided on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on July 1, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you received a phone call to setup an appointment for mental health services which you denied. You state that you hung up the phone and did not receive any other services. 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 $30 copayment for specialist services. 

The medial records show that you had a specialist visit on July 1, 2021, where you discussed multiple conditions. Therefore, you are responsible to pay the $30 copayment. 

You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services you received on May 4, 2021.

You asked the Plan to waive the copayment for the urgent care services. You say that you have gone to this provider before with no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for urgent care services. 

You have been asked to pay a $35 copayment for the urgent care services. This copayment applies regardless of whether or not you have been charged in the past. 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 urgent care services you received on May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on August 26, 2020.
You asked the Plan to pay for code 70544. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on August 26, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear provided on April 15, 2021.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says your Plan does not include reimbursement for out-of-network vision services. Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided with a network optical provider. We looked at the file and the Plan's rules. The file shows that the eyewear was not provided by the Plan's network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have to pay for eyewear provided on
April 15, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on June 9, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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 50% coinsurance for laboratory services provided by an
out-of-network provider. Based on the Plan's contract, you are only responsible for your 50% coinsurance for
the laboratory services you received. Therefore, we decided that the Plan has to pay for the laboratory services
provided on June 9, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on July 22, 2021.
You asked the Plan to waive the copayment for lab services. You say that you had these labs done as part of a
physical. The Plan denied your request. The Plan says the copayment applied 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 $10
copayment for Medicare-covered lab services. The labs performed were diagnostic in nature and not part of a routine physical. You have been asked to pay a
$10 copayment for lab services. Lab services fall within the outpatient diagnostic tests and therapeutic services
and supplies benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for lab services provided on
July 22, 2021.