Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost share amount forthe core build up (D2950) provided on August 20, 2020.You asked the Plan to pay the full cost share amount forthe dental service. You say that you were charged toomuch for the core build up. You say that you should have only been charged 50%. You say that you should not have paid for the dental rider for September since you used up your benefits in August. You say thatThe Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan says that this benefit was exceeded. The Plan says that after the annual maximum is exhausted, any remaining charges are your responsibility. The Plan also says that there is no record of a call to remove the dental rider for the month of September 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 annual maximum benefit of $1,000 has been exceeded.Date of ServiceCPT CodeBilled AmountAllowed AmountPlan PaidYourShareDate Paid7/28/2020D0120$71$49$49$07/31/2020D0274$76$58$58$0D1110$106$92$92$0D1206$50$50$50$08/20/2020D2391$166$163$163$08/22/2020D2330$160$150$150$09/9/2020D1206$50$50$50$09/11/20208/20/2020D2750$1,165$1,089$544.50$544.509/15/2020D2950$315$279$92.50$186.50TOTAL:$1,249The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility.Therefore, we decided that the Plan does not have to pay more forthe core build up (D2950) provided on August 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on August 28, 2020.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthoses have not been met.
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 shoulder-elbow-wrist-hand orthosis (L3960). Our reviewer says that the orthosis is not medically necessary. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. An adequate history and a physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for the enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination
of the shoulder. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the tub transfer bench (E0245) purchased from the out of network (OON) provider on July 14, 2020.
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item is not payable as it was purchased from an out of network provider.
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 issue reimbursement 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to issue reimbursement for this item. Therefore, we decided that the Plan does not have to issue reimbursement for the tub transfer bench (E0245) purchased from the out of network (OON) provider on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99211) provided on June 19, 2020.
You asked the Plan to pay for an office visit. You say that this is a covered service. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say all charges, except for therapies, telehealth originating site facility fee, PPV, influenza virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined and reported under revenue code 0510. We find that the billing of these services is not supported in the medical record. Specifically, they were reported with revenue code 0450 rather than 0510. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99211) provided on June 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance services and inpatient hospital care provided August 21, 2020, to August 28, 2020.You asked the Plan to waive the copayment forthe ambulance services and inpatient hospital care. You say that you would like thiscopayment waived.The Plan denied your request. The Plan says the copayment has processed correctly in this case.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 $395 copayment for ambulance services and a $492 copayment per day for days 1-4 for inpatient hospital care. You have been asked to pay a total cost share of $395 copaymentfor the ambulance services and a $1968 copayment($492 copayment x 4 days)for the inpatient hospital care. 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 forthe ambulance services and inpatient hospital care provided August 21, 2020, to August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for periodic oral evaluation (d0120), prophylaxis (D1110) bite wing x-rays (D0274), and the unspecified adjunctive service (D9999) provided.

You asked the Plan to reimburse you for the dental services. You say that you were reimbursed for a claim  for services with the same provider. You say that you were advised that the payment for the services in March 2020 was a mistake as the provider had opted out of Medicare. You say that you checked prior to your appointment to make sure there was no problem with the insurance. You also say that this claim should be paid since the previous one was.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. 

The Plan says that payment cannot be made for services that are rendered by a dentist that has opted out of Medicare.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 reimburse you for periodic oral evaluation (d0120), prophylaxis (D1110) bite wing x-rays (D0274), and the unspecified adjunctive service (D9999) provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on September 28, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you were told that you wouldn't have a copayment for this. You say that you cannot afford this. The Plan denied your request. The Plan says the correct copayment has been 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 $35 copayment for outpatient diagnostic tests/in-network/x-rays. You have been asked to pay a $35 copayment for an ultrasound. A diagnostic ultrasound is billed the same as an x-ray; therefore, the correct copayment has been applied. An ultrasound falls within the outpatient diagnostic tests/in-network/x-rays 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 an ultrasound provided by a participating provider on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and coinsurance for the office visit with a specialist (99203) and a Triamcinolone injection (J3301) provided on June 2, 2020.
You asked the Plan to waive the copayment and coinsurance for the office visit and drug administration. You say that you should not have any cost sharing responsibilities because you were eligible for Medicaid with your previous health plan. The Plan denied your request. The Plan says you are still eligible for Medicaid benefits and the provider has been informed for billing purposes. However, the Plan says that office visits with a specialist have a $40 copayment and Part B drugs have a 20% coinsurance.
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 $40 copayment for an office visit with a specialist and a 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $40 copayment for an office visit with a specialist and a 20% coinsurance for Medicare Part B drugs. The office visit falls within the Physician/Practitioner services benefit category, and the Triamcinolone injection falls within the Medicare Part B drugs benefit category. You have been asked to pay $40 for the office visit and $1.20 for the Triamcinolone. The Plan's allowed amount for Triamcinolone is $6.00 ($6.00 x 20% = $1.20). 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 and coinsurance for the office visit with a specialist (99203) and a Triamcinolone injection (J3301) provided on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on July 13, 2020, to September 13, 2020.You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree with this. The Plan denied your request. The Plan says the correct coinsurance has been 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 durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $565.67. The total amount you are being asked to pay is $113.15 ($565.67 x 20% = $113.15). Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider on July 13, 2020, to September 13, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided by a participating provider on September 11, 2020. You asked the Plan to waive the copayment for ambulance services. You say that you were not transported. You say that the ambulance just checked your vitals. The Plan denied your request. The Plan says the correct copayment has been 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 $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. There is a $250 copayment applied for ambulance stabilization when there is no transport; therefore, the correct copayment has been applied. Ambulance services 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 ambulance services provided by a participating provider on September 11, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the single bifocal lens and anti-reflective lens coating provided on June 23, 2020. 

You asked the Plan to pay for these services. You say that your benefit was not exhausted. The Plan denied your request. The Plan says that that you have used your $300 benefit towards eyewear. 

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 file provided by the Plan does not confirm that you have exhausted your eyewear benefit of $300. The file does not include documentation showing the eyewear claims or payment made on these claims. Therefore, we decided that the Plan has to pay for the single bifocal lens and anti-reflective lens coating provided on June 23, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home health medical supplies provided on September 25, 2020.
You asked the Plan to waive the coinsurance for the home health medical supplies. You say that you were told your home health visits are covered 100% but are now being charged for the supplies. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Home Health Agency Care. You have been asked to pay 20% coinsurance for the home health medical supplies. The home health medical supplies fall within the Home Health Agency 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 coinsurance for the home health medical supplies provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visit to urgent care provided on September 15, 2020.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be charged because you were directed to visit the emergency room. The Plan denied your request. The Plan says medical records show you were evaluated by the urgent care department. Urgent care services have a 45$ copayment.
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 urgently needed services. You have been asked to pay a $45 copayment for the urgent care visit. An urgent care visit falls 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 the visit to urgent care provided on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950) and crown (D2740) provided on October 7, 2020.
You asked the Plan to pay for the dental services. You say that you would like reconsideration because these services should be fully covered. The Plan denied your request. The Plan says these services have been paid at the allowable rate and you are responsible for the applicable cost share.
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. We looked at your request, the Plan rules and the file. Based on this information we decided that your cost sharing amount has been applied correctly. The record indicates that these services were rendered by an out-of-network provider. You have been billed for the difference between the MAC payment made from the Plan to the provider and the amount the provider billed. Therefore, we decided that the Plan does not have to pay for the core buildup (D2950) and crown (D2740) provided on October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid 150 mcg tablet.
You asked the Plan to pre-approve Synthroid. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited to only the drugs covered under your Part B medical benefit.
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 Synthroid 150 mcg tablet.
Benefits for Synthroid 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: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit received on August 28, 2020.You asked the Plan to waive the copayment forthe office visit. You say that these services were for test results and you feel you should not have to pay a copayment for it.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 $25 copayment for physician/practitioner services. You have been asked to pay a $45 copayment for each specialist office visit. The office visit falls within the physician/practitioner 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 forthe office visit received on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided.

You asked the Plan to waive the copay for the services provided. You say that you had your ears checked before you could get a hearing test.The Plan denied your request. The Plan says the copay 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 $30 copay for services provided by a specialist. 

You have been asked to pay a $30 copay for the services provided. The services fall within the physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copay forthe specialist office visit provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea routine transport for a total of 31 miles.You asked the Plan to pre-approvethese services. You say that you have an appointment for surgery and need coverage.The Plan denied your request. The Plan says the request exceeds the benefit limit.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 routine transportation with a 30 mile limit per trip.We looked at your request, the records in the case file, and the rules. The file shows that you are requesting transportation for a total of 31 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have topre-approvea routine transport for a total of 31 miles