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

We decided that the Plan has to pay for mycophenolic acid, oral, 180 mg (CPT code J7518) and pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for the first prescription in a 30-day period (CPT code Q0511) provided on April 29, 2021, through May 28, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says that the claim was processed correctly, as it contains the same diagnostic codes, procedure codes, dates of service and provider information as claim 820211270520134, which was paid on May 10, 2021. The Plan states additional information was not received to differentiate the claims as separate services received on the same date of service.

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. Review of the file does not show any provider remittance were paid for the services requested. The remittance provided was for a date of service, April 5, 2021. Therefore, this claim is not a duplicate claim. The dates of service requested for payment are from April 29, 2021, through May 28, 2021. Therefore, we decided that the Plan has to pay for mycophenolic acid, oral, 180 mg (CPT code J7518) and pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for the first prescription in a 30-day period (CPT code Q0511) provided on April 29, 2021, through May 28, 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 extraction, erupted tooth or exposed root (elevation and/or forceps removal) (CPT code D7140 X 2, intraoral - periapical each additional radiographic image (CPT code D0230), and intraoral - periapical first radiographic image (CPT code D0220) provided to the enrollee on December 16, 2020.
You asked the Plan to pay for the dental services. You say that the enrollee was under the impression that these were covered under their Plan. The Plan denied your request. The Plan says the services are not a covered benefit under the plan.
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. The services are not listed in your EOC as a covered benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (CPT code D7140 X 2, intraoral - periapical each additional radiographic image (CPT code D0230), and intraoral - periapical first radiographic image (CPT code D0220) provided to the enrollee on December 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, spine, lumbosacral; minimum of 4 views (CPT code 72110) provided to the enrollee on July 2, 2020.
You asked the Plan to pay for the x-ray. You say that please process this claim for payment as we billed the claim to the wrong Payer ID Number for 2020 claims. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the x-ray was not filed until February 16, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for radiologic examination, spine, lumbosacral; minimum of 4 views (CPT code 72110) provided to the enrollee on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nitroglycerine tablets.
You asked the Plan to pre-approve self-administered drugs. You say that at this time it would be dangerous to change the state of the enrollee's medication since he is stable on the medication. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve nitroglycerine tablets.
Benefits for self-administered drugs 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: Partially Favorable

We decided that the Plan has to waive the coinsurance for chemotherapy drugs and administration provided on December 24, 2020. We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration provided from January 21, 2021, to May 14, 2021.
You asked the Plan to waive the coinsurance for chemotherapy drugs and administration. You say that you believe you hit your out-of-pocket maximum. The Plan says that the coinsurance applied was correct.
We decided that the Plan has to waive the coinsurance for chemotherapy drugs and administration provided on December 24, 2020.
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 did not provide evidence that you had not met your 2020 out-of-network out-of-pocket maximum of $10,000. Therefore, we decided that the Plan has to waive the coinsurance for out-of-network chemotherapy drugs and administration provided on December 24, 2020.
We also decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration provided from January 21, 2021, to May 14, 2021.
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 chemotherapy drugs and administration. You have been asked to pay a 20% coinsurance for out-of-network chemotherapy drugs and administration provided on January 21, 2021, February 18, 2021, and March 18, 2021. You reached your out-of-network out-of-pocket maximum of $7,500 on March 18, 2021.
You have been asked to pay a 20% coinsurance for out-of-network chemotherapy drugs and administration provided on April 16, 2021, and May 14, 2021. You reached your in-network out-of-pocket maximum of $3,800 on March 18, 2021.
Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy drugs and administration provided from January 21, 2021, to May 14, 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: Favorable

We decided that the Plan has to pay for the physician services (01214, 99199, 76942) provided on November 19, 2020.
You asked the Plan to pay for the physician 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 has not provided any evidence that the claims were previously paid and shown to be duplicate claims. Therefore, we decided that the Plan has to pay for the physician services (01214, 99199, 76942) provided on November 19, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to lab services you received on January 19, 2021.
You asked the Plan to waive the deductible applied to the lab services. You say that a network lab sent your specimens to a non-contracted lab, but you have no control over that. You would like this cost sharing covered. The Plan denied your request. The Plan says these services were not processed as out-of-network. The Plan says that regardless of the network status of the provider, the lab services applied to your annual deductible, and you had not met your deductible at the time of these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $400 deductible which applies to lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services were received on January 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied to lab services you received on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261) provided on April 5, 2021.
You asked the Plan to pay for hearing aids. You say that you disagree with the charges as it is a lot of money. The Plan denied your request. The Plan says you have exhausted your benefit.
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 contract says the first $500 for hearing aids is covered at 100%; there is 80% coverage for next $1,500 per person, per 2-year period. We looked at the file and the Plan's rules. The records show that the Plan has covered a total of $1,700 (first $500 + $1,500 = $1,700). The remaining balance is your responsibility as you have exhausted your two-year hearing aid allowance. 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 pay for hearing aids (V5261) provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an office visit and Medicare Part B drugs provided on April 13, 2021.

You asked the Plan to waive the cost-sharing for an office visit and Medicare Part B drugs. You say that you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 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 $5 copayment for each in-network Primary Care Physician visit for Medicare-covered benefits.

Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Medicare-covered Part B prescription drugs provided in-network. The allowed amount of this claim is $709.06, resulting in a coinsurance amount of $141.81 ($709.06 x 20%). 

You have been asked to pay a $5 copayment for an office visit and a 20% coinsurance for Medicare Part B drugs. An office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits, benefit category. Medicare Part B drugs fall 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 cost-sharing for an office visit and Medicare Part B drugs provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam - two surfaces, primary or permanent (D2150) provided May 28, 2021.
You asked the Plan to pay for the amalgam. You say that you were not satisfied with the work done by the original network provider and chose to see a different provider to put in a new filling. The Plan denied your request. The Plan says the service was provided out-of-network without prior authorization, and therefore it is not covered. Your provider concerns are being addressed separately.
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 amalgam when the services are rendered by a participating provider. We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the amalgam have not been met. Therefore, we decided that the Plan does not have to pay for the amalgam - two surfaces, primary or permanent (D2150) provided May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray and office services provided on May 7, 2021.

You asked the Plan to pay for the x-ray and office services. You say that a clinic visit is a covered benefit under your policy. You state x-rays are not covered by the doctor visit should be covered. The Plan denied your request. The Plan says the claim and type of service (TOS) submitted by provider is listed as third-party outpatient facility.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-ray and office services have not been met. Your 2021 EOC shows that services required by third parties is a service not covered by Medicare. A hospital outpatient clinic visit and a radiologic examination for admission to a residential institution is not covered under any condition. Therefore, we decided that the Plan does not have to pay for the x-ray and office services provided on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 29, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were placed in a hallway all night until you were discharged. The Plan denied your request. The Plan says the copayment 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 $390 copayment per day, for days 1 to 4 for inpatient hospital care. You have been asked to pay a $390 copayment per day for inpatient hospital care. The records show you were inpatient for one day. The EOC confirms that $390 is the required copayment for this service. 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 inpatient hospital care provided on April 29, 2021. Your complaint about your experience with the hospital 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 copayment for cataract surgeries provided on February 11, 2021, March 18, 2021, and June 24, 2021.
You asked the Plan to waive the copayment for cataract surgeries. You say that you are not satisfied with the surgery on your eyes. You say that it has not resolved your problem. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment for surgery performed at an Ambulatory Surgical Center (ASC). You have been asked to pay a $200 copayment for cataract surgeries. Cataract surgeries fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 cataract surgeries provided on February 11, 2021, March 18, 2021, and June 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on May 5, 2021, and May 19, 2021.

You asked the Plan to waive the copayment for cataract surgery. You say that the hospital charge should be covered. You say bills can, and often do, go to collections. The Plan denied your request. The Plan says you have been asked to pay 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 $325 copayment for each outpatient hospital facility visit. 

You have been asked to pay a $325 copayment for each cataract surgery. Cataract surgery 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 for cataract surgery provided on May 5, 2021, and May 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar (CPT code 72158) provided to the enrollee on June 25, 2020.
You asked the Plan to pay for the MRI. You say that please process this claim for payment as we billed the claim to the wrong Payer ID Number for 2020 claims. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the MRI was not filed until February 16, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for MRI, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar (CPT code 72158) provided to the enrollee on June 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided January 7, 2021.
You asked the Plan to pay for the critical care. You say that you would like the services covered. The Plan denied your request. The Plan says there were no medical records submitted and therefore the service cannot be verified or approved.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We find that CPT code 99291 is not supported in the record. Specifically, the Plan has requested that medical records be supplied to support the billing of 99291. The necessary medical records were not received. Based on the limited information available, we cannot confirm that Medicare rules for coverage of the critical care have been met. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (99291) provided January 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on April 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the radiology services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the radiology services provided on April 16, 2021 by an out-of-network (OON) provider.