Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to hold you harmless for the coinsurance for outpatient surgery you had an an outpatient hospital facility on August 28, 2020.  You asked the Plan to hold you harmless for the outpatient surgery coinsurance. You say that you are a Qualified Medicaid Beneficiary (QMB), so this coinsurance should be covered in full.  You stated that you provided this hospital your Medicaid information as well as your Plan card, so they have all of the appropriate documentation they need to process the coinsurance. The Plan denied your request. The Plan says that it has tried to contact the provider to advise them to file a claim with your Medicaid, but they have been unsuccessful.  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 $0 or 20% coinsurance for outpatient surgery.  The contract also says that depending on your level of Medicaid eligibility, you may not be responsible for the coinsurance for outpatient hospital services.  The Plan says you must pay 20% coinsurance for the outpatient surgery coinsurance. We do not agree.  You have stated, and the Plan has confirmed, that you are a QMB entitled to full Medicaid benefits.  According to your contract, you do not pay cost sharing for outpatient surgery at a hospital if you are a QMB.  The contract does seem to indicate that the provider should submit claims for the coinsurance to your Medicaid plan. This provider apparently has failed to do so.  However, this provider is a contract provider with the Plan.  It is the Plan's job to monitor provider behavior and to ensure that enrollees are given the benefits to which they are entitled.  It is the Plan's obligation to ensure that their plan providers are following the rules.  They have not done so.  Your contract says that as a QMB, you shouldn't be responsible for this coinsurance.  The Plan must work with their own plan provider to ensure that you are not burdened with cost sharing which, under your contract, is not your responsibility.  The Plan should work together with this contract provider to ensure you are not responsible for this outstanding balance. Therefore, we decided that the Plan has to hold you harmless for the coinsurance for outpatient surgery you had an an outpatient hospital facility on August 28, 2020.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0676).  You asked the Plan to pay for a pneumatic compression device. You say that the item should b covered. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for urgently needed services provided on July 6, 2021.  You asked the Plan to waive the copayment for urgently needed services. You say that the facility did nothing to treat your condition and recommended that you go to the emergency room. 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 $35 copayment for urgently needed services.   The medical records show that you received urgently needed services on July 6, 2021. Therefore, you are responsible to pay the $35 copayment.   You have been asked to pay a $35 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on July 6, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services provided on March 19, 2021.  You asked the Plan to pay for ambulance services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. 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 ambulance services provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist visits provided from April 7, 2021, to May 4, 2021.  You asked the Plan to waive the copayments for specialist visits. You say that these were follow-up visits and you should not owe a copayment. 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 $40 copayment for specialist visits.   You had specialist visits from April 7, 2021, to May 4, 2021 for a total of 6 visits. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $40 copayment per each visit. However, you are only being asked to pay the total allowed amount of $222.20, which is less than the total copayment amount.   You have been asked to pay $222.20 for specialist visits. Specialist visits fall 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 copayments for specialist visits provided from April 7, 2021, to May 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with polyp removal you had at an ambulatory surgery center on July 9, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy with polyp removal. You say that you thought this colonoscopy would be covered in full. 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 $175 copayment for outpatient surgery in an ambulatory surgery center.   Records show that this diagnostic colonoscopy was not ordered for screening purposes.  Rather, it was done as a surveillance since you had a prior adenomatous lesion.  This procedure was ordered and performed as a diagnostic, not screening procedure.  Diagnostic colonoscopies are considered surgical services. That is why the diagnostic colonoscopy with polyp removal falls within the outpatient surgery in an ambulatory surgery center 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 diagnostic colonoscopy with polyp removal you had at an ambulatory surgery center on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit (99214) rendered on May 28, 2021.  You asked the Plan to waive the copayment for an office visit. You say that you were seen by the provider for your yearly physical and you were not charged at the time of service. You also say that you are now being billed a $5 copayment for the office visit. You also say you do not agree with the billing and there should be no charge per benefits. 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 there is no coinsurance, copayment, or deductible for the annual wellness visit. Your contract with the Plan also says that the applicable cost-sharing will apply to any non-preventive services you receive during this visit that you must pay. Your contract with the Plan also says that there is a $5 copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  You have been asked to pay a $5 copayment for an office visit. The records show that there were non-preventive services received during your annual wellness 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 office visit (99214) rendered on May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) services (72156, A9575) provided on May 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for MRI services. You say that the provider did not know they were out-of-network. 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 magnetic resonance imaging (MRI) services (72156, A9575) provided on May 5, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injections and therapy services provided on June 3, 2021.  You asked the Plan to pay for the injections and therapy services. The Plan denied your request. The Plan says the Transcutaneous Electrical Nerve Stimulation (TENS) device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit.    The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. Medicare rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections and therapy services have not been met. Specifically, the physical therapy services at issue in this case were rendered by a provider who is not licensed to provide physical therapy. In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the injections and therapy services provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intraoral x-ray provided on April 20, 2021.  You asked the Plan to pay for the intraoral x-ray. You say that your dental provider was selected based on the Plan's list of in-network providers. You say that the x-ray benefit was not exceeded, and payment should be made in full. The Plan denied your request. The Plan says the claim reprocessed as a one-time exception toward your in-network benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of one intraoral x-ray per calendar year. The Plan paid for the intraoral x-ray provided on March 16, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for single antibody stain tests (88341 and 88342) provided on May 4, 2020.  You asked the Plan to pay for lab tests 88341 and 88342. You say that you are appealing with records to support the codes billed. The Plan denied your request. The Plan says the denial of payment for these services is correct, because codes 88341 and 88342 have a procedure-to-procedure (PTP) edit with code 88360 and are not separately payable without an appropriate modifier.  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 codes 88341 and 88342 are column II codes to column I code 88360. 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 single antibody stain tests (88341 and 88342) provided on May 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a nurse practitioner on June 25, 2021.  You asked the Plan to waive the copayment for the telehealth visit. You say that you didn't ask this nurse practitioner to call you, so you don't think you should have to pay this. The Plan denied your request. The Plan says the nurse practitioner from whom you received these services is not your selected primary care provider, so the specialist 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 $30 copayment for in-office and telehealth specialist services.   You have been asked to pay a $30 copayment for the telehealth visit. The records from this visit show that you consented to the 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 the telehealth visit you had with a nurse practitioner on June 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vitamin injections and therapy services provided on June 15, 2020.  You asked the Plan to pay for the vitamin injections and therapy services. The Plan denied your request. The Plan says the Transcutaneous Electrical Nerve Stimulation (TENS) device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. Medicare rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vitamin injections and therapy services have not been met. Specifically, the physical therapy services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical therapy.   In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the vitamin injections and therapy services provided on June 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laboratory services and the chest x-ray provided on August 11, 2021.  You asked the Plan to waive the copayment for the laboratory services and the chest x-ray. You say that you feel this should be covered with your pre-op testing benefits. You say this is a standard procedure. The Plan denied your request. The Plan says you have been 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 $6 copayment for laboratory tests. Your contract also clearly says that you must pay a $55 copayment for each standard x-ray. The contract also says that if you get additional services with your laboratory test, the cost sharing amount for the other service will be the total applied.   You have been asked to pay a $6 copayment for the laboratory test and a $49 copayment for the chest x-ray, for the total of $55. The laboratory services fall within the Outpatient Hospital Services benefit category. The chest x-ray falls in 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 the laboratory services and the chest x-ray provided on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the spinal cord stimulation procedure you received at an outpatient hospital facility on April 26, 2021.  You asked the Plan to waive the copayment for the spinal cord stimulation procedure. You say that there has been an overpayment to the surgeon for 30 minutes of surgery and you do not owe anything. 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 $400 copayment for outpatient surgery at a hospital outpatient facility.   You have been asked to pay a $400 copayment for the spinal cord stimulation procedure. The spinal cord stimulation procedure falls within the outpatient surgery at a hospital outpatient facility 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 spinal cord stimulation procedure you received at an outpatient hospital facility on April 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on August 2, 2021.  You asked the Plan to pay for the dental services. You say that you went for an x-ray of your tooth. You say that you talked about the next steps. You also say that you received a bill for the services. The Plan denied your request. The Plan says the limited oral evaluation is not listed as a covered service. The Plan says that the periapical x-ray is not listed as a covered service either.  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 dental services you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on August 2, 2021.