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

 We decided that the Plan does not have to waive the coinsurance for prostate cancer mRNA gene expression profiling provided on October 12, 2021.  You asked the Plan to waive the coinsurance for prostate cancer mRNA gene expression profiling. You say that you did not receive genetic testing and this bill is not for you. 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 20% coinsurance for genetic tests.   The medical records show that you were pre-approved and received prostate cancer mRNA gene expression profiling on October 12, 2021. This is considered genetic testing. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $3,873 and 20% of that is $774.60.   You have been asked to pay the total coinsurance amount of $774.60 for prostate cancer mRNA gene expression profiling. Prostate cancer mRNA gene expression profiling 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 prostate cancer mRNA gene expression profiling provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and a periapical radiographic imaging (D0220) provided by a participating provider on October 26, 2021.

You asked the Plan to pay for a limited oral evaluation and a periapical radiographic imaging. You say that The Plan denied your request. The Plan says the rendered dental services are not covered 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, 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 a limited oral evaluation (D0140), and a periapical radiographic imaging (D0220) provided by a participating provider on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5258) purchased on August 17, 2021, from an out-of-network provider.  You asked the Plan to pay for the hearing aids. You say that you purchased these out-of-pocket online and would like the Plan to pay their regular portion. The Plan denied your request. The Plan says the provider in this case is not part of the Plan's specified routine hearing vendor network. Hearing aids purchased out-of-network are not covered.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are supplied by the Plan's specified routine hearing vendor network.       We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5258) purchased on August 17, 2021, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) arthrocentesis, aspiration and/or injection (20610) triamcinolone acetonide injection (J3301) provided August 12, 2021.  You asked the Plan to waive the copayment for the office visit. You say that you were charged an additional $20 for a specialist when this was a visit with your primary care physician, which you paid $20. No specialists was involved. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage  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 $40 copayment for each specialist's office visit.   You have been asked to pay $40 copayment for the office visit. The office 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 the outpatient office visit (99214) arthrocentesis, aspiration and/or injection (20610) triamcinolone acetonide injection (J3301) provided August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for yttrium-90 radiation therapy provided on June 30, 2021.

You asked the Plan to waive the coinsurance for the yttrium-90 radiation therapy. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance 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 5% coinsurance for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.

You have been asked to pay a 5% coinsurance for the yttrium-90 radiation therapy ($17,397.64 x 5% = $869.88). Radiation therapy 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 yttrium-90 radiation therapy provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to authorize treatment with a non-participating specialist.  You asked the Plan to authorize treatment with a non-participating specialist. You say that there are no specialist in-network that can provide the proper care. The Plan denied your request. The Plan says there are specialist in-network that will provide the proper care.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to authorize treatment with a non-participating specialist. Our reviewer says that that you do not meet the criteria for treatment with the requested out-of-network provider. Our physician reviewer found the record indicates that you have Ehlers Danlos and lipedema that requires plastic surgery. The record does not indicate that the Plan is unable to provide this service. The record shows that there are in-network providers available to provide the needed services. Out-of-network treatment is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of treatment with a non-participating specialist have not been met. Therefore, we decided that the Plan does not have to authorize treatment with a non-participating specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a ROMTech adaptive rehabilitation exercise bike.  You asked the Plan to pre-approve a ROMTech adaptive rehabilitation exercise bike. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ROMTech adaptive rehabilitation exercise bike. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not reveal that the enrollee requires this device with Bluetooth technology for the enrollee's condition and recovery over standard physical therapy and a home exercise program for the enrollee's left knee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ROMTech adaptive rehabilitation exercise bike have not been met. Therefore, we decided that the Plan does not have to pre-approve a ROMTech adaptive rehabilitation exercise bike.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on September 30, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the specialist office visit. You say that services were provided to the enrollee. The Plan denied your request. The Plan says the enrollee was not referred from their primary care physician and the provider for this service is an out-of-network provider.

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 specialist office visit provided on September 30, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an esophageal motility test (91010) provided on September 7, 2021.  You asked the Plan to waive the copayment for the Esophageal motility test. You say that the services should be covered as it was a simple test and you weren't there for that long. 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 $100 copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   You have been asked to pay a $100 copayment for an Esophageal motility test. Esophageal motility tests fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 esophageal motility test (91010) provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chemical cauterization rendered on September 23, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 17250 (chemical cauterization of granulation tissue) and 11043 (muscle and/or fascia debridement).   Code 17250 is a column II code with a modifier indicator of 1 when billed with column I code 11043. Code 17250 was not billed with an appropriate modifier to allow Therefore, we decided that the Plan does not have to pay for the chemical cauterization rendered on September 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed before coverage can be approved.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 20, 2021, to June 25, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you were readmitted due to an infection, and you feel that this stay should be considered a continuation of the original stay. 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 $375 copayment for days 1-5 for inpatient hospital care.    You received inpatient hospital care from June 20, 2021, to June 25, 2021. This is considered a new inpatient hospital admission. Therefore, you are responsible to pay a $375 copayment for days 1-5 (June 20, 2021, to June 24, 2021). The total amount you owe is: $375 (copayment) x 5 (inpatient days) = $1,875.   You have been asked to pay the total copayment amount of $1,875 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from June 20, 2021, to June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 4, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that services were provided to the enrollee and the doctor's office would not do a referral for the services. The Plan denied your request. The Plan says the provider is a non-participating provide and the referral was not authorized by the attending physician.

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 laboratory services provided on August 4, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services provided on October 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the hospital services. You say that services were provided to the enrollee out of medical necessity. The Plan denied your request. The Plan says the provider is not in network and the enrollee was not referred by a network provider.   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 hospital services provided on October 7, 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 influenza virus vaccine (90662) and the administration of the vaccine (G0008) rendered by the out-of-network (OON) provider on October 18, 2021.  You asked the Plan to pay for this item/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 item/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 item/service 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 this item/service. Therefore, we decided that the Plan does not have to pay for the influenza virus vaccine (90662) and the administration of the vaccine (G0008) rendered by the out-of-network (OON) provider on October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crowns - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided June 8, 2021.  You asked the Plan to pay for the crowns and core buildup. You say that you explained your dental needs and feel that plan representatives did not do a good job helping with your benefits. The Plan denied your request. The Plan says these services are not covered under your 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, 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 crowns - porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided June 8, 2021.   Your complaint about plan representatives potentially providing poor service and benefit details is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a colonoscopy provided on November 9, 2021.  You asked the Plan to waive the deductible for a colonoscopy. You say that you were told that the colonoscopy would be fully covered with no 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.   Your contract with the Plan says that there is a $750 deductible which applies to outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.   The medical records show that you had polyps removed during a colonoscopy on November 9, 2021. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay your share of the cost-sharing charges. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the $750 deductible.   The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on November 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy provided on November 9, 2021.