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

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on June 1, 2021.  You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was submitted with an inappropriate place of service code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code G0483 is not supported in the record. Specifically, this claim was submitted with the laboratory place of service code while the records suggest the member;'s face-to-face services were rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing 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 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 14, 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 the services are not covered.  The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary.        We looked at the file and Medicare rules. The services are billed under code 81455. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 28, 2021, to March 29, 2021.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed correctly.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was not reported with a G code with the same date as service as Q code Q5001. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 28, 2021, to March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 3, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $60 copayment for Urgently needed services.       You have been asked to pay a $60 copayment for an urgent care visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent care visit provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acupuncture services (97810 and 97811) provided on December 11, 2020.  You asked the Plan to pay for the acupuncture services. You say that you would like reconsideration because the acupuncture services were medically necessary. The Plan denied your request. The Plan says this provider is not considered a physician.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture services are covered when rendered by or under the supervision of a physician. The record shows that this provider is not a physician and there is no indication that these services were rendered under the supervision of a physician. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810 and 97811) provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on July 22, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered screening test.  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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services provided on October 12, 2021.  You asked the Plan to waive the copayment for lab services. You say that you disagree with how there are three claims related to this service. 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 $15 copayment for lab services.   You have been asked to pay a $15 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 October 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extremity study (93971) provided on March 22, 2021.  You asked the Plan to pay for the extremity study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support that this service was rendered more than once on the same date of service.  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 93971 is duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study.  We find that CPT code 93971 is not supported in the record. Specifically, the record indicates that one unit of CPT code 93971 has been approved by the Plan. The documentation submitted does not support that this service was rendered more than once on the same date of service. Based on this information, we decided that Medicare rules for coverage of the extremity study have not been met. Therefore, we decided that the Plan does not have to pay for the extremity study (93971) provided on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a supply allowance for therapeutic continuous glucose monitor (CGM) (K0553).  You asked the Plan to pre-approve a CGM supply allowance. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is not insulin treated with atleast three daily injections.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM supply allowance have not been met. Therefore, we decided that the Plan does not have to pre-approve a supply allowance for therapeutic continuous glucose monitor (CGM) (K0553).
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) provided on August 4, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that this claim for a Medicare-covered service should be paid by the Plan. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel (0242U) provided on August 4, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room services (99285, 99219) provided on July 30, 2021.  You asked the Plan to pay for the emergency room services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has been billed incorrectly based on Medicare coding regulations.  The Plan must follow Medicare rules.   The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. In this case, no medical records were provided to corroborate the services as they were billed. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room services (99285, 99219) provided on July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99203) and an x-ray of the knee (73564) provided on November 9, 2021.  You asked the Plan to waive the copayment for the specialist office visit and an x-ray of the knee. You say that the services should be covered as you feel you should only be charged 1 copayment. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $35 copayment for Outpatient diagnostic tests and  a $35 copayment for therapeutic services and supplies and Physician/Practitioner services, including doctor's office visits.   You have been asked to pay a $35 copayment for a specialist office visit and a $35 copayment for an x-ray of the knee. X-rays fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category and the specialist office visit falls within and 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 office visit (99203) and an x-ray of the knee (73564) provided on November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for surgical pathology provided on October 12, 2021.  You asked the Plan to waive the copayment for surgical pathology. You say that you disagree with how the service was processed under three claims. 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 $15 copayment per provider, per day for lab services.  You have been asked to pay a $15 copayment for surgical pathology. Surgical pathology 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 surgical pathology provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited re-evaluation (D0170) and comprehensive periodontal evaluation (D0180) provided on August 26, 2021, and September 30, 2021.  You asked the Plan to pay for the problem focused limited re-evaluation and comprehensive periodontal evaluation. You say that you feel the Plan should pay for these services. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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 problem focused limited re-evaluation (D0170) and comprehensive periodontal evaluation (D0180) provided on August 26, 2021, and September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on July 10, 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 targeted genomic sequence analysis (0037U) rendered by the out-of-network (OON) provider on July 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medication assisted methadone treatment (G2067) rendered by the out-of-network (OON) provider from May 1, 2021, through June 4, 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 medication assisted methadone treatment (G2067) rendered by the out-of-network (OON) provider from May 1, 2021, through June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for office visit services provided on May 25, 2021, by an OON provider.  You asked the Plan to pay for the office visit services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.     The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for office visit services provided on May 25, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a telehealth visit with a specialist provided on November 2, 2021.  You asked the Plan to waive the copayment for a telehealth visit with a specialist. You say that this was a short telephone call with a physician's assistant. 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 visits, including telehealth visits.  You have been asked to pay a $30 copayment for a telehealth visit with a specialist. A telehealth visit with a specialist 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 telehealth visit with a specialist provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the periodic oral exam (D0120) provided on July 28, 2021.  You asked the Plan to pay for the dental service. You say that you had a gum infection that needed to be treated. The Plan denied your request. The Plan says that 2 routine oral exams are covered per year. The Plan also says the frequency limit has been exceeded.  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. Specifically, the Plan did not provide documentation to show that previous oral exams have been paid. Additionally, the provided documentation does not support the services on the corrected claim that was submitted for the date of service in this case. Therefore, we decided that the Plan has to pay for the periodic oral exam (D0120) provided on July 28, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 15, 2020, to December 18, 2020.

You asked the Plan to waive the copayment for the inpatient hospital. You say that the services should be covered as you never wanted to be admitted in the first place. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $300 copayment for days 1-5 of Inpatient hospital care.

You have been asked to pay a $300 copayment for days three days of inpatient hospital care ($300 x 3 = $900). 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 inpatient hospital stay provided from December 15, 2020, to December 18, 2020.