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

We decided that the Plan does not have to waive the copayments for the x-rays of the thoracic spine and cervical spine you had on August 26, 2021.
You asked the Plan to waive the copayments for the two x-rays. You say that you should not have to pay these copayments because you didn't see a doctor on these dates. The Plan denied your request. The Plan says you were charged these copayments 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 $10 copayment for each x-ray service. You have been asked to pay a $10 copayment for each of the two x-rays. These copayments apply regardless of whether or not you see a doctor. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the x-rays of the thoracic spine and cervical spine you had on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on April 8, 2021.

You asked the Plan to reimburse you for hearing aids. You say that The Plan denied your request. The Plan says hearing aids are covered only if the member goes to an in-network provider.

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 provide by a network hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by a network hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 22, 23, 24, 25, 26, and 27.

You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says there is no clinical evidence to support medical necessity.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crowns when the services are medically necessary and reasonable.

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 crowns. Our reviewer says that the criteria for crowns has not been met. Our physician reviewer found the provided x-rays and photos indicate minimal structural damage to any of the involved teeth, but there is noted incisal wear across all of the lower anterior teeth. Our reviewer found that in this case, there is only incisal wear from attrition seen, and placement of crowns would involve significant cutting of the intact teeth to be able to be placed. Our physician reviewer also found that given the provided x-rays and photos, it is clearly seen that there is minimal breakdown of the teeth in question and that abrasion or attrition is the only issue involving the teeth. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 22, 23, 24, 25, 26, and 27.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the injection procedures you had at an outpatient hospital facility from April 21, 2021, to July 15, 2021.

You asked the Plan to waive the copayments for the injection procedures. You say that you were told that insurance required you to have these injections before surgery could be discussed. You said that if the Plan requires this, then you shouldn't have to pay for it. The Plan denied your request. The Plan says you were charged these copayments 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 $325 copayment for outpatient surgery and other services at an outpatient hospital facility.

You have been asked to pay a $325 copayment for the injection procedures. The injection procedures fall within the outpatient surgery and other services at an outpatient hospital facility benefit category. These copayments apply regardless of the reason for the services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the injection procedures you had at an outpatient hospital facility from April 21, 2021, to July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy procedure you had at an outpatient hospital facility on June 17, 2021.

You asked the Plan to waive the copayment for the biopsy procedure. You say that you were only in the room for about 10 minutes and you do not believe the copayment matches the service you received. 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 $350 copayment for outpatient surgery and services at an outpatient hospital facility. 

You have been asked to pay a $350 copayment for the biopsy procedure. The biopsy procedure falls within the outpatient surgery and services at an outpatient hospital facility benefit category. This copayment applies regardless of how long the procedure lasts. 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 biopsy procedure you had at an outpatient hospital facility on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81270, 81279, and 81338 provided on June 22, 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 are not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT codes 81270, 81279, and 81338 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file does not support that one code was submitted for the panel provided.

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81270, 81279, and 81338 provided on June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology testing provided on June 15, 2021.

You asked the Plan to pay for the testing services. You say that the referring physician ordered specialized testing. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnosis listed on the claim.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

The file shows that Fluorescence in situ hybridization (FISH) testing was provided. We looked at the file and the rules. We find that the testing is not supported in the records provided. The records do not show the testing was ordered due to suspected bladder cancer, or for the management of a specific treatment plan. 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 pathology testing provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on August 19, 2021.
You asked the Plan to pay for a comprehensive oral evaluation. You say that you did not feel safe at the other dentist because some of the workers were not vaccinated. The Plan denied your request. The Plan says the benefit limit for a comprehensive oral evaluation has already been exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a comprehensive oral evaluation once every 36 months. We looked at the file and Medicare rules. Evidence was provided that shows a comprehensive oral evaluation was provided on January 20, 2020. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation has already been exhausted. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a participating provider on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 20, 2021, by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the OON services. You say that you are not required to obtain prior
authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved
in advance.
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 referring provider is not a network provider with the Plan. 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 lab services provided on August 20, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (K0606) provided from May 27, 2021, to June 27, 2021.
You asked the Plan to waive the coinsurance for an automatic external defibrillator. You say that you told the provider that you did not want or need such a vest, and the provider said it would only be for a month. You also say that on July 24, 2021, you took off the vest, packed it up and left a message for your heart specialist that you were doing so. You also say that you are low income and are begging us to reconsider. 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 you must pay 20% coinsurance of the cost for each Medicare-covered item for durable medical equipment (DME) and related supplies.
You have been asked to pay $700 in coinsurance, which is 20% of the allowed amount for each month, for two months, of the use of an automatic external defibrillator ($3500 allowed amount x 20% = $700 each month). An automatic external defibrillator falls within the Durable Medical Equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (K0606) provided from May 27, 2021, to June 27, 2021.
Your complaint about potentially being forced to wear the vest 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Stelara injection provided on August 2, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that you were informed that the injection would be a $50 copayment. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B drugs, including gastroenterology drugs. You have been asked to pay $1,222, which is 20% of the allowed amount for the injection ($6,110 allowed amount x 20% coinsurance = $1,222). The injection falls within the Medicare Part B Prescription Drugs 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 a Stelara injection provided on August 2, 2021.
Your complaint about misinformation from the Plan customer service representatives 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the $90 copayment charged for emergency room services provided on July 24, 2021.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.

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 each emergency room visit. Whether or not you are transferred to another facility does not negate the copayment for the originating facility.

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 $90 copayment charged for emergency room services provided on July 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on August 6, 2021.
You asked the Plan to pay for anesthesia. You say that this is payable and was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because deep sedation was not achieved, and this anesthesia code does not crosswalk with the procedure.
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 01992 is anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position.
We asked our coder 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 anesthesia. Our reviewer says that code 01992 does not meet the criteria for payment. Our reviewer found the procedure report describes moderate sedation, as Versed and Fentanyl were administered "for the lowest depth necessary to complete the procedure and agree upon with the patient in the preoperative area." There is a more appropriate code to report for this service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia provided on August 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services coded as 99601 and 99602 provided on March 3, 2020.
You asked the Plan to pay for the home infusion services. You say that these services were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says these services are not covered by Medicare or by the Plan.
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 99601 is home infusion/specialty drug administration, per visit (up to 2 hours). The CPT Code Manual definition of code 99602 is home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary procedure). We find that CPT codes 99601 and 99602 are not eligible for payment according to Medicare rules. Specifically, these codes both have a status code of "I" under the Physician Fee Schedule. This status code indicates that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and
payment for, these services. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services coded as 99601 and 99602 provided on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgent care services provided on August 12, 2021.
You asked the Plan to waive the copayment for the urgent care services. You say that the provider advised you to go to the emergency room without examining you. 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 $65 copayment for each urgent care visit. You have been asked to pay a $65 copayment for the urgent care services. Urgent care 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 urgent care services provided on August 12, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the $55 copayment for a comprehensive eye examination provided on July 26, 2021.
You asked the Plan to waive the $55 copayment for a comprehensive eye examination. The Plan denied your request. The Plan says that the claim was processed correctly according to the customary allowable amount.
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. Specifically, the Plan has not provided us with the exact benefit rule (section and page number) in your Evidence of Coverage that supports the Plan's cost share that is applicable for this service. Therefore, we decided that the Plan has to waive the $55 copayment for a comprehensive eye examination provided on July 26, 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 pre-approve additional non-emergency transportation.
You asked the Plan to pre-approve additional non-emergency transportation. You say that you have an appointment and need transportation urgently. You say that you are alone and have no one to provide transportation. The Plan denied your request. The Plan says you exhausted the covered benefit of 52 trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Re-enrollment in the
same plan does not reset your benefits. Therefore, we decided that the Plan does not have to pre-approve
additional non-emergency transportation
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray (D0220), and porcelain crown (D2740) provided from February 10, 2021, to March 16, 2021.
You asked the Plan to pay for the dental services. You say that your dentist was advised by a plan representative that $400 would be paid by your insurance. You say that the services were paid and then reversed. You also say that the payment should not have been reversed. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a dentist that has opted out of Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed by a dentist that has opted out of Medicare 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), periapical x-ray (D0220), and porcelain crown (D2740) provided from February 10, 2021, to March 16, 2021.