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

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on October 22, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you had some tests and lab services, but you were never given any medication or prescription.  You also say that you were returned to the waiting room after these tests to wait, and you left before seeing a doctor in person. 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 $120 copayment for emergency room visits.   You have been asked to pay a $120 copayment for the ER visit. This copayment applies each time you visit the ER, regardless of the extent of services you receive in the ER. The copayment applies even if you leave before seeing a doctor. 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 (ER) visit you had on October 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 13, 2021.

You asked the Plan to pay for periodontal maintenance. You say that you need to have three cleanings every year to preserve your teeth as long as possible. The Plan denied your request. The Plan says your dental benefit covers a maximum of two cleanings per year. You have already had two cleanings covered in 2021.

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. The Plan covers up to 2 cleanings per year. 

Though the Plan offers a dental benefit in excess of Medicare coverage, this service is requested in a frequency that exceeds what is covered under this benefit. Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on October 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 5,
2021, to August 3, 2021.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act.
The Plan denied your request. The Plan says the SNF care was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the SNF care have not been met. Specifically, the file does not show that the enrollee received
skilled service on a daily basis. Therefore, we decided that the Plan does not have to pay for the skilled nursing
facility (SNF) care provided from July 5, 2021, to August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on October 16, 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. Medicare rules say that billing more than 1 unit of service per 30 days of code K0553 will be denied as not reasonable and necessary.  

We looked at the file and Medicare rules. The file shows that more than one unit of service was billed within the 30 day period for the CGM supplies. 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 continuous glucose monitor (CGM) supplies rendered on October 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a vaccine provided on October 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the vaccine. You say that you gave your insurance cards to the doctor so you figured he would have checked the insurance. The Plan denied your request. The Plan says services were obtained from 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 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 a vaccine provided on October 1, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the perfusionist services provided on June 28, 2021.  

You asked the Plan to pay for the perfusionist services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says payment for these services is included in the payment to 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. Based on this information, we decided that Medicare rules for coverage of the autologous blood or component, collection and processing, special pump services (and washed red blood cells have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. Payment for these services is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the perfusionist services provided on June 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam - one surface, primary or permanent (D2140)
and provisional crown- further treatment or completion of diagnosis necessary prior to final impression
(D2799) provided June 7, 2021, and the periodic oral evaluation - established patient (D0120) and prophylaxis
- adult (D1110) provided October 4, 2021.
You asked the Plan to pay for the amalgam, provisional crown, periodic oral exam and dental cleaning. You
say that you were told these services would be covered. The Plan denied your request. The Plan says these
services are not covered because the provider has 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. The Plan covers the amalgam,
provisional crown, periodic oral exam and dental cleaning when you see any dental provider who accepts
Medicare patients in the United States and has not opted out of Original Medicare.
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent,
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information,
we decided that the Plan's rules for coverage of the amalgam, provisional crown, periodic oral exam and dental
cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the amalgam - one
surface, primary or permanent (D2140) and provisional crown- further treatment or completion of diagnosis
necessary prior to final impression (D2799) provided June 7, 2021, and the periodic oral evaluation -
established patient (D0120) and prophylaxis - adult (D1110) provided October 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transports rendered September 8, 2021 to
September 28, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate
primary diagnosis code. 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 ambulance
transports rendered September 8, 2021 to September 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided on September 13, 2021.
You asked the Plan to pay for incontinence supplies. You say that you have a bladder problem and wear
incontinence supplies every day. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on
September 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for a single
photon emission computed tomography (SPECT) scan provided on August 9, 2021.
You asked the Plan to waive the coinsurance for an injection and copayment for a SPECT scan. You say that
the services were provided in a specialist office so you should not pay for outpatient services. The Plan denied
your request. The Plan says the proper cost share was applied for the services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B prescription drugs and a $150 copayment for CT, MRI, MRA, and SPECT
scans. The total amount allowed for the injection was $238.20 with a coinsurance amount of $47.64 ($238.20
total amount allowed x 20% coinsurance). The copayment for the SPECT scan was $150. The total cost share
amount was $197.64 ($47.64 coinsurance + $150 copayment).
You have been asked to pay a $197.64 cost share for an injection and a SPECT scan. An injection falls within
the Medicare Part B prescription drugs benefit category.
The SPECT scan 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 coinsurance for an injection and copayment for a single photon
emission computed tomography (SPECT) scan provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on July 26, 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 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Fundus photography and an eye refraction provided on September 13, 2021.  You asked the Plan to pay for Fundus photography and an eye refraction. You say that you are a diabetic patient who requires regular vision services due to bleeding of the eye. The Plan denied your request. The Plan says Fundus photography is not a covered service, regardless of the provider network status. The claim for an eye refraction processed correctly.  The Plan must follow Medicare rules. Medicare rules say that Fundus photography is not covered for routine screening. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.   We looked at the file, the Plan's rules and Medicare rules. Medicare says that Fundus Photography is not covered for routine screening. Medicare and the Plan do not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for Fundus photography and an eye refraction provided on September 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 16, 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 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, fluorescence in situ hybridization (FISH) 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 the laboratory services rendered on March 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Fluorescence in situ Hybridization (FISH) testing provided
to the enrollee on March 23, 2021 and coded as 88120.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says this testing is not covered when ordered as a screening without confirmation of disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in
the Medicare rules section, are not covered.
This 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 Fluorescence in situ Hybridization
(FISH) testing provided to the enrollee on March 23, 2021 and coded as 88120.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on September 9, 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 00140 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 00140 is anesthesia for procedures on eye; not otherwise specified. 

We find that CPT code 00140 is not supported in the medical record. Specifically, the records show that the enrollee received a lens procedure and there is a more appropriate anesthesia code for these services. 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 anesthesia services rendered on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on August 22, 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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be
exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. 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 critical care services rendered on August 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided by a network
provider on November 19, 2021.
You asked the Plan to waive the copayment for the podiatry visit. You say that you have diabetes and should
have a $0 copayment for the podiatry visit. The Plan denied your request. The Plan says you have been asked
to pay 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 $40
copayment for each Medicare-covered visit (medically necessary foot care).
You have been asked to pay a $40 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry
services" benefit category. The medical record shows you were seen for discoloration of the left great toenail in
addition to the routine care.
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 podiatry visit provided by a network provider on
November 19, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on September 14, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that this copayment should be waived because it is related to COVID-19. 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 $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. According to your Plan's website, they are only waiving cost sharing for COVID-19 vaccines, diagnostic testing, and virtual visits for the diagnosis of COVID-19. Standard cost sharing applies for all other services. 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 (ER) visit you had on September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on May 10, 2021 by an out-of-network (OON) provider.  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 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 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 the drug testing provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998)
provided on September 10, 2021.
You asked the Plan to pay for the ambulance response. You say that you chose not to go to the Emergency
Room due to concerns about the pandemic. The Plan denied your request. The Plan says ambulance services
are not covered when there is no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 10, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no
transport (A0998) provided on September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on June 11, 2021.
You asked the Plan to pay for the testing services. You say that the test is to guide the decision on a repeat
biopsy. The Plan denied your request. The Plan says screening without a valid diagnosis is not a benefit.
The Plan follows Medicare rules. The rules explicitly say that ConfirmMDx testing is only covered under
certain medical indications.
We looked at the file and the rules. The records show that the enrollee has not undergone a previous biopsy.
Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we
decided that the Plan does not have to pay for the ConfirmMDx testing provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
September 30, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee 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 must 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 to the
enrollee on September 30, 2021.