Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the routine transportation services provided from November 12, 2020 to April 26, 2021.
You asked the Plan to pay for the routine transportation services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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. In this case, the Plan provided no documentation that was provided to the enrollee specifically informing the enrollee to go through a broker for the Plan's transportation services. The Plan's contract with the enrollee clearly says the enrollee would expect to have no cost share for in-network and out-of-network routine transportation services. Therefore, we decided that the Plan has to pay for the routine transportation services provided from November 12, 2020 to April 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 22, 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 testing is not covered.
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 cardiovascular risk assessment panel, 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 rendered on December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services represented by code 86077 provided on February 5, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 represented by code 86077 provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 27, 2020.
You asked the Plan to pay for services from this provider. You say that in your appeal to the Plan and in a letter sent directly to this office that your appeals are not being read and/or understood and you believe the Plan is required to cover these services. The Plan denied your request. The Plan says the Medicare data base shows this provided opted out of Medicare on July 1, 2016.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician services provided on February 27, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services represented by code 76700 provided on July 3, 2021.
You asked the Plan to pay for code 76700. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 76700 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services represented by code 76700 provided on July 3, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the electroconvulsive therapy (ECT) provided on September 21, 2020.
You asked the Plan to pay for the ECT services. You say that this provider is the only one in the facility able to provide this type of treatment. As such, he should be paid for the services rendered. The Plan denied your request. The Plan says that this service was not authorized. The provider asked for the authorization to be voided.
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 has stated that there was an authorization that was voided which is why this service is not covered. However, it is not clear what the authorization was for, and also this request was made nearly one year after the services took place, in August 2021. The Plan has not indicated the network status of this facility, nor have they addressed the appeal argument that there was not another provider able to render this treatment. With these material omissions, we find that the denial of payment is not supported. Therefore, we decided that the Plan has to pay for the electroconvulsive therapy (ECT) provided on September 21, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 15, 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 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the chest x-rays you had on March 11, 2021, and April 8, 2021.
You asked the Plan to waive the copayments for the chest x-rays. You say that you have had many x-rays in the past and have never been charged. The Plan denied your request. The Plan says it initially processed your claims incorrectly, charging coinsurance. The Plan has reprocessed your claims and is charging a $10 copayment for each date of service. The Plan says that these copayments were charged 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 basic imaging services (including x-rays). You have been asked to pay a $10 copayment for each of the chest x-rays. The chest x-rays fall within the basic imaging 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 copayments for the chest x-rays you had on March 11, 2021, and April 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the breast you had on November 5, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you were never charged a copayment for previous MRIs and you were not aware that a copayment would be due. 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 $100 copayment for diagnostic radiology services (including MRIs). You have been asked to pay a $100 copayment for the MRI. The MRI falls within the diagnostic radiology 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 the magnetic resonance imaging (MRI) of the breast you had on November 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 27, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER the day before and were not treated properly, which is why you had to return. You said that you should not have to pay a copayment for this second visit. 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 $110 copayment for each emergency room visit.
You have been asked to pay a $110 copayment for the ER visit. This copayment applies regardless of the reason for the visit. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 27, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment (A9300) purchased on February 11, 2021.
You asked the Plan to pay for fitness equipment. You say that you called the Plan twice to confirm information on the fitness reimbursement and was told it would be covered. You also say you should be reimbursed as no one explained that the Covid-19 benefit ended in 2020. The Plan denied your request. The Plan says the fitness equipment purchased after December 31, 2020, is not eligible for reimbursement under the Plan's health and wellness benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract for 2020 states that the Plan can pay up to $250 per calendar year toward your cost of a membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture and/or nutritional counseling. As of October 1, 2020, and until December 31, 2020, this benefit may also be used toward the purchase of exercise equipment that you can use at home. Purchases made prior to October 1, 2020 or after December 31, 2020, do not qualify. The Plan's rules for coverage of gym benefits have not been met because this purchase was made after the Plan's policy changes that became effective on October 1, 2020 through December 31, 2020. Therefore, we decided that the Plan does not have to pay for fitness equipment (A9300) purchased on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound debridement procedures provided at an outpatient hospital facility on March 29, 2021, and April 5, 2021.
You asked the Plan to reduce the copayments for the wound debridement procedures. You say that these services should not be considered surgeries and that the copayment should only be $45. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan also says that because the allowed amounts for these dates of service ($172.33 per date of service) is less than the enrollee's copayment obligation, the enrollee is responsible for the full allowed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for each outpatient hospital facility visit.
The enrollee has been asked to pay a $225 copayment for the wound debridement procedures. Because these services occurred at an outpatient hospital facility, the wound debridement procedures fall within the outpatient hospital facility visit benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayments for the wound debridement procedures provided at an outpatient hospital facility on March 29, 2021, and April 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on January 21, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were advised that if you were admitted to the hospital, that you would not have to pay for ambulance services. 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 $90 copayment for ambulance services. You have been asked to pay a $90 copayment for the ambulance services. There is no provision in your contract for a waiver of this copayment if you are admitted to the hospital. 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 ambulance services you received on January 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99204) and a magnetic resonance imaging (MRI) (72146) provided on September 23, 2020, and January 8, 2021.
You asked the Plan to waive the copayment for an office visit and an MRI. You say that you should be refunded the office visits and the MRI because you did not receive the care that was discussed. The Plan denied your request. The Plan says the copayments you are being charged is correct.
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 physician/practitioner services, including doctor's office visits with a specialist. Your contract with the Plan also clearly says that you must pay a $110 copayment for each outpatient diagnostic test and therapeutic services and supplies. You have been asked to pay a $45 copayment for an office visit with a specialist and a $110 copayment for an MRI. The EOC confirms that $45 is the required copayment for an office visit with a specialist. The EOC also confirms that $110 is the required copayment for an MRI. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit with a specialist (99204) and a magnetic resonance imaging (MRI) (72146) provided on September 23, 2020, and January 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the two cataract surgeries you had at an outpatient hospital facility on March 24, 2021, and March 31, 2021.
You asked the Plan to waive the copayments for the two cataract surgeries. You say that you cannot believe that your insurance does not cover the entire cost of the these surgeries. You said that you were never told that your insurance wouldn't cover everything. 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 $290 copayment for outpatient surgery in an outpatient hospital facility. You have been asked to pay a $290 copayment for the two cataract surgeries. The two cataract surgeries fall
within the outpatient surgery in an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the two cataract surgeries you had at an outpatient hospital facility on March 24, 2021, and March 31, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography angiography (CTA) of the abdomen rendered on May 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 procedure code 74175 is 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 74175 (CTA abdomen without dye) and 74176 (computed tomography scan of the abdomen and pelvis without contrast). Code 74176 is a column II code with a modifier indicator of 1 when billed with column I code 74175. Code 74176 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography angiography (CTA) of the abdomen rendered on May 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fee for services provided between 10PM and 8AM on March 17, 2021, billed with code 99053.
You asked the Plan to pay for the services as billed. You say that this should be paid. The Plan denied your request. The Plan says this is not a payable code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 99053 has a status indicator of "B" in the Physician Fee Schedule. This means that payment for this code is bundled in payment for other services.
Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the fee for services provided between 10PM and 8AM on March 17, 2021, billed with code 99053.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) provided April 30, 2021.
You asked the Plan to pay for the oral exam. You say that you previously went in for a tooth extraction which was not performed, and you were not informed you would be billed for an exam. If you had realized you would be billed for that appointment, you would not have gone in for your exam on the date of service at issue. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the oral exam twice per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that oral exams were previously covered on January 26, 2021, and April 29, 2021. Additionally, the Plan provided documentation showing that they investigated your concerns and found that the prior exam was billed correctly. Based on this information, we decided that the Plan's frequency limit for coverage of the oral exam has been exceeded.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) provided April 30, 2021.