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

 We decided that the Plan does not have to waive the copayment for the psychotherapy visit you had on May 24, 2021.  You asked the Plan to waive the copayment for the psychotherapy visit. You say that you did not see the provider on this date. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that they contacted this provider and confirmed that you were indeed seen by this provider on this date of service.  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 copayment for outpatient mental health visits.   You have been asked to pay a $30 copayment for the psychotherapy visit. The psychotherapy visit falls within the outpatient mental health visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the psychotherapy visit you had on May 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the topical application of fluoride (D1208) provided on September 16, 2021.  You asked the Plan to pay for the fluoride application. You say that this service was covered in 2019, and you were not informed that this had changed. The Plan denied your request. The Plan says this service is not covered by your dental benefit. This service also was not covered in 2020.  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 topical application of fluoride (D1208) provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and administration (90471) provided on August 10, 2021.  You asked the Plan to pay for a Tdap vaccine and administration. You say that you should not be penalized for getting this shot in your doctor's office. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of you prescription drug plan.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine and administration. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine and administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine (90715) and administration (90471) provided on August 10, 2021.   Benefits for a Tdap vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for acupuncture, initial 15 minutes (97810) acupuncture, acupuncture, each additional 15 minutes (97811) provided August 24, 2021.  You asked the Plan to pay for acupuncture services. You say that for each appointment you were charged and paid a $20 copay for the services provided. You were not informed that the services were not covered. The Plan denied your request. The Plan says that this service is not covered under the Plan benefits.  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.  In this case, the records show that the rendering provider is an in-network provider. The Plan has not provided any records supporting that the acupuncture services provided was not for chronic low back pain.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for acupuncture, initial 15 minutes (97810) acupuncture, acupuncture, each additional 15 minutes (97811) provided August 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.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgery services provided on April 28, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    The medical records provided do not show that CPT codes 36247 and 75710, billed with the -59 modifier, were a distinct procedural service. The documentation provided does not show that CPT code 75625 is supported. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the OON provider on July 14, 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 the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99336) rendered by the OON provider on July 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the diagnostic imaging services provided from January 1, 2020, to January 31, 2020.  You asked the Plan to waive the copayments for the diagnostic imaging services. You say that you understood that there would be no copayments for physician visits or treatments. You also say that you do not have income and have difficulty paying this bill. The Plan denied your request. The Plan says the copayment amount 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 $60 copay for Medicare-covered Therapeutic Radiological Services.    You have been asked to pay a $60 copay for the diagnostic imaging services. Diagnostic imaging services falls within the Medicare-covered Therapeutic Radiological Services benefit category. The record shows that you received 21 treatments, leaving you responsible for a $1,260 copay. 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 diagnostic imaging services provided from January 1, 2020, to January 31, 2020.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient hospital observation provided August 20, 2021.  You asked the Plan to waive the copayment for the outpatient hospital observation. You say that you cannot afford the copayment and you thought your insurance covered everything. The Plan denied your request. The Plan says you were initially overcharged for this service. The Plan has adjusted the claim and a $200 copayment has been correctly 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 $200 copayment for outpatient hospital observation services.  You have been asked to pay a $200 copayment for the outpatient hospital observation. The outpatient hospital observation falls within the Outpatient hospital observation benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.   This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital observation provided August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99202) provided on August 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that the doctor who provided this service is in network with the Plan. The Plan denied your request. The Plan says the claim did not list the doctor you mentioned in your appeal request as being the rendering, or referring provider. The Plan also says that the provider listed in the claim is not a network provider with the Plan and the services were not rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 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 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 an office visit (99202) provided on August 30, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment's for advance imaging services, radiological services, and physical therapy in an outpatient hospital.  You asked the Plan to waive the copayment's for an advance imaging service, radiological service, and physical therapy. You say that you were transferred to another hospital, and it should be paid. The Plan denied your request. The Plan says the claim was processed correctly with the proper copayment's 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 $150 copayment for advance imaging services in an outpatient hospital. You were charged $125 is less than the $150 copayment charge. Your contract with the Plan clearly says that you must pay a $25 copayment for radiological services in an outpatient hospital. Your contract with the Plan also clearly says that you must pay a $20 copayment for physical therapy in an outpatient hospital.   You have been asked to pay a $125 copayment, a $25 copayment, and a $20 copayment for an advance imaging service, radiological service, and physical therapy in an outpatient hospital. Advance imaging services, radiological services, and physical therapy in an outpatient hospital falls within the Outpatient hospital 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's for an advance imaging service, radiological service, and physical therapy in an outpatient hospital.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the re-amputation (27596) provided by an assistant surgeon on June 2, 2021.  You asked the Plan to pay for the re-amputation (27596). You say that the provider was in urgent need to perform revision and the severity of the case required an assistant to be present. You say that the assistant can provide aid in the operation as well as a safe closure and the medical records should be reviewed for reconsideration. The Plan denied your request. The Plan says multiple physicians/assistants are not covered for this service.    The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 27596. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the re-amputation (27596) have not been met. Therefore, we decided that the Plan does not have to pay for the re-amputation (27596) provided by an assistant surgeon on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 480.  You asked the Plan to pay for the inpatient hospital services billed with DRG 480. You say that you would like this claim to be reprocessed so you can be reimbursed per contract for DRG 480. The Plan denied your request. The Plan says DRG 480 is not supported as the diagnosis of displaced intertrochanteric fracture of right femur, initial encounter for closed fracture.  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 primary diagnosis code, S72.141A, defined as Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture. 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 inpatient hospital services billed with DRG 480. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found that the medical records did not support the billing of displaced intertrochanteric fracture of right femur, initial encounter for closed fracture.   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 billed with diagnosis related group (DRG) code 480.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on March 9, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483) provided on February 9, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).      We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient mental health services provided from August 10, 2021, to August 17, 2021.  You asked the Plan to pay for the services provided. You say that the provider was qualified and suitable for mental health needs. The Plan denied your request. The Plan says the services were rendered by a provider who is ineligible to bill Medicare.  The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.    The file shows that you received services from a licensed professional counselor. We looked at the file and Medicare rules. This type of provider is not eligible to participate in Medicare. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services provided from August 10, 2021, to August 17, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the echocardiography services coded 93313 provided on July 13, 2021.  You asked the Plan to pay for the echocardiography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 93313 is a column II code to column I code 93314. 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 the echocardiography services coded 93313 provided on July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation care provided on August 31, 2021, through September 10, 2021.  You asked the Plan to waive the copayment for the inpatient rehabilitation care. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $310 copay each day one through seven for inpatient hospital care.   You have been asked to pay a $310 copay each day one through seven for the inpatient rehabilitation care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient rehabilitation care provided on August 31, 2021, through September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the disposable contact lenses (S0500), deluxe frames (V2025), anti-reflective coating (V2750), and progressive lenses (V2781) provided August 20, 2021.  You asked the Plan to provide additional payment for the disposable contact lenses, deluxe frames, anti-reflective coating, and progressive lenses. You say that You needed to use an out-of-network provider due to allergies. The Plan denied your request. The Plan says a one-time exception has been made to reimburse you your $175 vision allowance.  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 up to a $175 allowance.  We looked at the file and the Plan's rules. In this case the Plan provided the full $175 reimbursement for the routine eyewear.  Therefore, we decided that the Plan does not have to provide additional payment for the disposable contact lenses (S0500), deluxe frames (V2025), anti-reflective coating (V2750), and progressive lenses (V2781) provided August 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the specialty care transport (SCT) ambulance transportation from hospital to hospital (A0434), provided on February 23, 2021.  You asked the Plan to waive the copayment for the SCT ambulance transport. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $250 copayment for ambulance services.   You have been asked to pay a $250 copayment for the SCT ambulance transport. This service falls within the ambulance 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 specialty care transport (SCT) ambulance transportation from hospital to hospital (A0434), provided on February 23, 2021.