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

 We decided that the Plan does not have to waive the copay for the podiatry services provided on August 19, 2021.  You asked the Plan to waive the copay for the services provided. The Plan denied your request. The Plan says the claim processed 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 copay for podiatry services.   You have been asked to pay a $30 copay for the services provided. The services fall within the podiatry 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 copay for the podiatry services provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the lidocaine HCl injection rendered on May 3, 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 that procedure code J2001 cannot be paid when billed with 20610.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan statse that a procedure to procedure (PTP) edit exists between codes J2001 (injection, lidocaine hcl for intravenous infusion, 10 mg) and 20610 (arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance); however, there is no edit between these two codes in the National Correct Coding Initiative (NCCI) PTP database. The Plan has not provided any further documentation or Medicare rules to support that code J2001 is not payable as billed. Therefore, we decided that the Plan has to pay for the lidocaine HCl injection rendered on May 3, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the post-cataract surgery eyeglasses (V2025, V2781, V2744) purchased on August 23, 2021.  You asked the Plan to pay for the eyeglasses. You say that you were told your lenses would be free, but you would have to pay for your frames. You were then told that these services would have no charge, and you cannot afford these costs. The Plan denied your request. The Plan says this claim was processed correctly, and you are responsible for the remaining cost.  The Plan must follow Medicare rules. The rules say that following cataract surgery, only standard frames and lenses are covered. Additional charges for deluxe frames will be denied as non-covered. Lens upgrades are not covered. The Plan offers an additional vision benefit to cover routine services. This benefit includes up to $300 one per calendar year toward the purchase and fitting of eyewear.  The eyeglasses purchased on August 23, 2021, following your cataract surgery, included deluxe frames (V2025), progressive lenses (V2781) and photochromatic tint (V2744). These services are not covered by Original Medicare and can only be paid up to the cost of basic lenses and standard frames. The Plan has provided discounts for these services and issued partial payment to reduce your costs for the non-Medicare covered services. Therefore, we decided that the Plan does not have to pay an additional amount for the post-cataract surgery eyeglasses (V2025, V2781, V2744) purchased on August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit for dental pain (99203) provided on June 5, 2021.  You asked the Plan to pay for an office visit for dental pain. You say that you needed this because you were in pain. The Plan denied your request. The Plan says this is not covered.  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 an office visit for dental pain (99203) provided on June 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing services provided from July 1, 2021, to July 14, 2021.  You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the criteria for a continued skilled nursing facility (SNF) stay were not met.  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 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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from July 1, 2021, to July 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the protective restoration (D2940) provided on September 1, 2021.  You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says protective restoration is not listed as a covered service.  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 protective restoration is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the protective restoration (D2940) provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the subcutaneous tissue debridement (11042) and the applications of a rigid leg cast (29445 x 4) provided from August 5, 2021, through
August 26, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $250 copayment per visit for outpatient surgery or procedure at an outpatient hospital.
You have been asked to pay $1,185.84 which includes a $250 copayment for the wound care provided.
Additionally, this amount includes a $233.96 copayment x 4=$935.84 for the applications of a rigid leg cast
provided as this was the Plan's allowed amount for these services, which is less than the applicable
copayments. 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 the subcutaneous tissue debridement
(11042) and the applications of a rigid leg cast (29445 x 4) provided from August 5, 2021, through
August 26, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out-of-network provider on August 2, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  The enrollee was referred for this service by a contract provider. The file does not show that the Plan provided notice that this service would not be covered. Under Medicare rules, this means this service is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the transtelephonic rhythm strip pacemaker evaluation (93293) rendered by the out-of-network provider on August 2, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion, for therapy, prophylaxis, or diagnosis, initial, up to 1 hour (96365), intravenous infusion, for therapy, prophylaxis, or diagnosis each additional hour (96366), and Gammagard liquid injection (J1569) provided May 21, 2021.
You asked the Plan to waive the copayment for the intravenous infusion and Gammagard liquid injection. You say that you had already reached your out-of-pocket maximum and don't feel you should be responsible for any
cost for these services. The Plan denied your request. The Plan says the cost-sharing was applied correctly up
to your out-of-pocket maximum.
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 $325
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including
but not limited to hospital or other facility charges and physician or surgical charges. You must pay 20% for
Medicare Part B Prescription drugs. The plan benefits say your in-network maximum out-of-pocket amount is
$4,700.
In this case the Plan provided documentation showing that you had $335.83 remaining in your out-of-pocket
maximum at the time services were rendered on May 21, 2021. You have been asked to pay a $325 copayment
for the intravenous infusion. The intravenous infusion and Gammagard liquid injection falls within the Hospital
outpatient facilities and ambulatory surgical centers benefit category. You have been asked to pay $10.83 for
the Gammagard injection. The Gammagard injection falls within the Medicare Part B prescription drugs
benefits category. This means that you have been asked to pay less than or equal to 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 intravenous
infusion, for therapy, prophylaxis, or diagnosis, initial, up to 1 hour (96365), intravenous infusion, for therapy,
prophylaxis, or diagnosis each additional hour (96366), and Gammagard liquid injection (J1569) provided May
21, 2021.
Your complaint about concerns about how your out-of-pocket maximum was calculated 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing provided on August 25, 2021.
You asked the Plan to pay for the testing services. You say that the testing reduces the number of unnecessary biopsies. The Plan denied your request. The Plan says the testing is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that 4Kscore testing is only covered under certain medical indications. We looked at the file and Medicare rules. In this case, there are insufficient medical records to show the coverage criteria were met. The records do not include other indications or contraindications for a biopsy. The records do not show the enrollee had an elevated prostate specific antigen (PSA) result. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing provided on August 25, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided from August 26, 2021, through August 27, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $90 copayment for emergency care services.   You have been asked to pay a $90 copayment for the emergency care visit provided. 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 visit (99285) provided from August 26, 2021, through August 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81599) provided June 9, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that to report a Comprehensive Genomic Profile (CGP) screening service providers should use 1 unit of code 81479 for the entire bundled multi-test panel.  We looked at the file and Medicare rules. The testing was reported using unbundled codes and not a single unit of code 81479. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81599) provided June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pontic (D6245) and two retainer crowns (D6740 x2) provided on September 28, 2021.  You asked the Plan to pay for the pontic and retainer crowns. You say that you had to have a tooth pulled and you feel the bridge is needed. The Plan denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits, but you did call prior to review the pre-determination for the same services and you were advised that they were not covered.  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 pontic (D6245) and two retainer crowns (D6740 x2) provided on September 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 31, 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 the OPPS status indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged.  We looked at the file and Medicare rules. Billed procedure codes 87077, 87086, 87186, 81001, J0696, and Q0162 have an OPPS status indicator of Q4 and have packaged payment under the OPPS payment system. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam (92014) provided on July 13, 2021, by an out-of-network provider.  You asked the Plan to pay for the eye exam. You say that you were told you could use this provider for these services. The Plan denied your request. The Plan says the provider in question is not part of the Plan's vision vendor network. Services obtained from vendors outside this network are not covered. The Plan also investigated your call logs with the Plan and found that a Plan representative did not tell you inaccurate information.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are received from a provider in the Plan's vision vendor network.  We looked at the file and the Plan's rules. The provider in this case is out-of-network. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) provided on July 13, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography, head (70544) provided September 4, 2021.  You asked the Plan to pay for the diagnostic service. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your request. The Plan says unbundled service.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. 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 magnetic resonance angiography, head (70544) provided September 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on October 29, 2020, by an out-of-network provider.
You asked the Plan to pay for psychotherapy services. You say that the services at issue are covered by Medicare. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.
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 psychotherapy services (90834) provided on October 29, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periapical x-ray (D0220), and 2 crowns (D2740) provided on September 22, 2021.  You asked the Plan to pay for the dental services. You say that the crowns were medically necessary. You say that your insurance includes a benefit of up to $1,000 for preventive care. You say that the services should be covered up to your maximum benefit of $1,000. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says that crowns are not listed as covered services.  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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on July 13, 2021. Additionally, crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220), and 2 crowns (D2740) provided on September 22, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services (86301) provided on May 24, 2021.
You asked the Plan to pay for code 86301. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the service billed (86301) is an exact duplicate to a claim that has already paid for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file, the Plan's contract and Medicare rules. The file shows that the claims are not considered to be exact duplicates per Medicare guidelines. The claims have different billed amounts, making these claims not duplicates of one another. Therefore, we decided that the Plan has to pay for the laboratory services (86301) provided on May 24, 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