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

We decided that the Plan does not have to waive the copayment for the radiologic examination, spine, cervical; two or three views (72040) provided May 26, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that please adjust the charges to reflect in-network for the claim. The Plan denied your request. The Plan says this 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 $50 copayment for in-network specialist's office. You have been asked to pay $33.17 for the diagnostic services. Since the allowed amount was less than the copayment amount, you are responsible for the lesser amount. The diagnostic service 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 the radiologic examination, spine, cervical; two or three views (72040) provided May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation treatment provided on February 1, 2021, and February 2, 2021, billed with code 97032.
You asked the Plan to pay for the electrical stimulation treatment. You say that this should be paid. The Plan denied your request. The Plan says a valid modifier was not appended to code 97032 for these dates.
The Plan follows Medicare rules. Medicare rules say that when two codes of an NCCI edit pair are billed, only the Column 1 code is payable unless a clinically appropriate modifier is used. We looked at the file and Medicare rules. Code 97032 is a Column 2 code in relation to code 92526 which was billed on the same date of service. No NCCI modifier was reported to justify bypassing the edit. Based on this
information, we decided that Medicare rules for coverage of the electrical stimulation treatment have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation treatment provided on February 1, 2021, and February 2, 2021, billed with code 97032.
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 your
cardiologist on May 7, 2021.
You asked the Plan to waive the copayment for the specialty telehealth visit. You say that you do not
understand why you are getting billed $45 for this service. 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 $45
copayment for telehealth visits with a specialist.
You have been asked to pay a $45 copayment for the specialty telehealth 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 your
cardiologist on May 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you more for the oxygen equipment you purchased on October 27, 2020.
You asked the Plan to reimburse you more for the oxygen equipment.. You say that you only collect disability, so purchasing this item was a large expense for you. The Plan denied your request. The Plan says you were reimbursed appropriately. While the Plan acknowledges that intially your claim was reimbursed incorrectly, they have reprocessed your claim and you have been reimbursed $640, which is 80% of the purchase price of $800.
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 durable medical equipment.
Records show that you paid $800 plus $62 in sales tax for the oxygen equipment. The Plan has reimbursed you $640 (which is 80% of the purchase price) for this item. Your Evidence of Coverage clearly states that you are responsible for 20% coinsurance for durable medical equipment, so the Plan reimbursed you appropriately. In addition, Medicare rules explicitly state that sales tax is not a covered benefit. This means that the Plan has paid you the correct amount for this item. Therefore, we decided that the Plan does not have to reimburse you more for the oxygen equipment you purchased on October 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation with a periodontist. 
 
You asked the Plan to pre-approve an evaluation with a periodontist. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
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 says covered dental 
services must be performed by a participating general dentist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an evaluation with a periodontist have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an evaluation with a periodontist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the continuous positive airway pressure 
(CPAP) device and supplies you rented from June 3, 2021, to July 3, 2021. 
 
You asked the Plan to waive the coinsurance for the CPAP device and supplies. You say that you do not want 
to pay monthly fees and you don't want to rent this item. The Plan denied your request. The Plan says you were 
charged this coinsurance correctly because this CPAP device is an item that must be rented. 
 
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 durable medical equipment. The contract also says that you are required to rent, and not 
purchase, some durable medical equipment. 

You have been asked to pay 20% coinsurance for the CPAP device and supplies. The CPAP device and 
supplies fall within the durable medical equipment 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 the continuous positive airway pressure (CPAP) device and supplies you rented from June 3, 
2021, to July 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215) provided on August 10, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you are requesting review of the medical records and please reprocess this claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 outpatient office visit (99215) provided on August 10, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits (97164).
You asked the Plan to pre-approve the additional therapy visits. You say that the additional therapy visits are medically necessary. The Plan denied your request. The Plan says the enrollee no longer requires the services of a skilled therapist.
The Plan follows Medicare rules. Medicare rules say that services that do not require the professional skills of a therapist to perform or supervise are not medically necessary. 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 additional therapy visits. Our reviewer says that the requested physical therapy visits are not medically necessary. Our physician reviewer found the record shows the patient has had prior extensive therapy, and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment. The patient should be able to transition to an independent home exercise program. 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 additional therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits (97164).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder assay provided on November 10, 2020.
You asked the Plan to pay for the CxBladder assay. You say that this was paid below the Medicare rate, and plans are required to pay the amount payable under Original Medicare. The Plan denied your request. The Plan says no payment has been made for this testing, the claim for which was denied as noncovered. This was the correct decision as the rules state Medicare does not pay for this test.
The Plan must follow Medicare rules. Medicare rules say that the CxBladder assay has been found to remain noncovered by Medicare after review of the literature. Therefore, we decided that the Plan does not have to pay for the CxBladder assay provided on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulance.

You asked the Plan to pre-approve Trulance. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing represented by code D4342 on tooth # 22 and 27 provided on June 16, 2021.

You asked the Plan to pay for dental code D4342 on tooth # 22 and 27. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D4342 is covered for one procedure per quadrant every two plan years. The Plan says that dental code D4342 was received on March 12, 2021 on tooth # 18 and 30. These teeth are located in the same quadrants as tooth # 22 and 27 respectively.

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.

We looked at the file, the Plan's contract and Medicare rules. The contract says dental code D4342 is covered for one procedure per quadrant every two plan years. The file shows that dental code D4342 was received on March 12, 2021 on tooth # 18 and 30. These teeth are located in the same quadrants as tooth # 22 and 27 respectively. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing represented by code D4342 on tooth # 22 and 27 provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 services provided by an out-of-network provider on February 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to make additional payment for the medical services provided on May 17, 2021.
You asked the Plan to make additional payment for the medical services. You say that you are new to this Plan and selected this provider as your assigned PCP. You later found that she is not in-network, but you relied on information from the Plan's website and feel you should not be liable for the out of network coinsurance. The Plan denied your request. The Plan says that the provider directory was reviewed, and this provider is only in-network at one location. Since the provider treated you at a different location, this was correctly paid as out of network.
The Plan must follow Medicare rules. Medicare rules say that health plans must disclose to its enrollees in clear, accurate terms all cost-sharing information. Your contract says that there is a $10 copayment for PCP visits provided in-network. Although the Plan indicates that this provider is only considered in-network at a single location, we find that it is not reasonable to expect that an enrollee would expect this to be the case. The Plan has attested to the fact that this provider is listed as in-network in their provider directory. As such, we find that you cannot be asked to pay more than the in-network cost sharing for this service. This claim was billed with an annual wellness visit code, but also a code indicating that evaluation of conditions beyond what is included in an annual wellness visit was provided. This means that the services fall within the "in-network Medicare-covered primary care physician (PCP) visit" benefit category. Therefore, we decided that the Plan has to make additional payment for the medical services provided on May 17, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive genetic cancer screening (81162, 81317, 81319, 81404, 81405, 81406, 81408, 81435, 81436) provided on November 10, 2020.
You asked the Plan to pay for a comprehensive genetic cancer screening. You say that this is supported in the records. The Plan denied your request. The Plan says this was a screening service.
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, a comprehensive genetic cancer screening, 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 a comprehensive genetic cancer screening (81162, 81317, 81319, 81404, 81405, 81406, 81408, 81435, 81436) provided on November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 19, 2021. 

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit. 
 
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 laboratory testing at issue in this appeal 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 provided on May 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing of 22 or more drug classes provided on May 13, 2021, billed with code G0483.
You asked the Plan to pay for the definite drug testing as billed. You say that this was billed correctly. The Plan denied your request. The Plan says that this code is not supported as only 19 drug classes are resulted on the lab report.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is supported in the medical record. Specifically, review of the lab report shows results for 26 drug classes as defined by the Current Procedural Terminology (CPT) manual. Based on this information, we decided that Medicare rules for coverage of the definite drug testing as billed have been met. Therefore, we decided that the Plan has to pay for the definitive drug testing of 22 or more drug classes provided on May 13, 2021, billed with code G0483.
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 pay for the inpatient hospital services rendered on May 20, 2020 to June 1, 2020.
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 submitted records do not support the billing of DRG 853 and diagnosis code A41.9.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 853 (infectious and parasitic diseases with or procedure with mcc) and diagnosis code A41.9 (sepsis, unspecified organism). 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 pay for these services. Our reviewer says that the submitted records do not support the billing of DRG 853 and diagnosis code A41.9. Our physician reviewer found the enrollee was admitted to the hospital with bilateral mastoiditis. Her white blood cell count increased to 22.2 and the blood cultures were positive for staphlococcus epidermidis. She was treated with intravenous Vancomycin. The enrollee demonstrated no clinical or laboratory evidence for sepsis. The billed DRG and diagnosis code are therefore not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered on May 20, 2020 to June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory testing at issue in this appeal 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 provided on January 15, 2021.