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

We decided that the Plan does not have to pay for the chiropractic services you received from August 1, 2019 to August 8, 2019.You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says the services are not manipulation of the spine.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from August 1, 2019 to August 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental consultation provided on December 18, 2018.You asked the Plan to pay forthe dental consultation. You say that your visit was medical in nature.The Plan denied your request. The Plansays that you are responsible for the costs of non-covered services.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe dental consultation provided on December 18, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 5, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the office would not allow your wife to take you. You say that you should not have to pay because you could have been transported without an ambulance. The Plan denied your request. The Plan says the copayment 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 $225 copayment for each Medicare-covered one-way trip in a ground ambulance. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance 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 the ambulance transport provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray, 2 views, and the hospital outpatient clinic visit provided from August 7, 2019 to August 8, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says that the services were not urgent or emergent in nature.
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 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 chest x-ray, 2 views, and the hospital outpatient clinic visit provided from August 7, 2019 to August 8, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional $60.06 towards a health club membership for the 2019 benefit year.
You asked the Plan to reimburse you an additional $60.06 towards a health club membership. You say that you submitted proof of payment to the Plan that shows you paid the gym for an entire year. The Plan denied your request. The Plan says you were reimbursed the correct amount based on the amount on the receipts provided to the Plan for the 2019 benefit year.
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. We looked at the file and the rules. The Plan's rules for coverage of gym benefits have not been met because it was determined that the proof of payment submitted shows a payment of $14.99 each month from January 17, 2019 to June 17, 2019, totaling $89.94. On August 9, 2019 you were reimbursed $89.94 towards the wellness allowance for the 2019 benefit year. The Plan can only reimburse you for the amount identified on the receipts provided, up to the benefit limit. You have not supplied additional information or receipts showing have paid the remaining $60.06 towards your gym membership for the 2019 benefit year. Therefore, we decided that the Plan does not have to reimburse you an additional $60.06 towards a health club membership for the 2019 benefit year.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on May 3, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that the enrollee was in an assisted living facility at the time of service. You say that the provider is not responsible for obtaining authorizations. You also say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee.
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 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 rest home visit provided on May 3, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided by the Lab from January 7, 2019 to May 15, 2019.
You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges
because you could not use your regular provider. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct 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 $5
copayment for lab services.
You received laboratory tests on January 7, 2019 and May 15, 2019. Therefore, you are responsible to pay a $5
copayment per each lab test. The total amount you owe is: $10.00.
You have been asked to pay the total copayment amount of $10.00 for laboratory tests. Laboratory tests fall
within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for laboratory tests provided by the Lab from January 7,
2019 to May 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forprosthetic devices and related supplies provided by "the provider" from May 29, 2019 to August 20, 2019.You asked the Plan to waive the coinsurance forprosthetic devices and related supplies. You say that you were told that you would not owe anything.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for prosthetic devices and related supplies. You received prosthetic devices and related supplies on May 29, 2019.The allowed amount is $929.64 and 20% of that is $185.93. You received prosthetic devices and related supplies on August 20, 2019. The allowed amount is $6,388.85 and 20% of that is $1,277.77. The total amount you owe is: $1,463.70.You have been askedto pay the totalcoinsuranceamount of $1,463.77for prostheticdevices and related supplies. Prosthetic devices and related supplies fallwithin the prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forprosthetic devices and related supplies provided by "the provider" from May 29, 2019 to August 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 22, 2019.You asked the Plan to waive the copayment for the emergency room visit. You say that you were checked into triage but were never seen by a physician. You say you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that they must pay a $90 copayment per visit for emergency care. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $90 copayment for emergency care.The enrollee has been asked to pay an $80.19 copayment for the emergency room visit. The emergency room visi tfalls within "Emergency care" benefit category. The record shows that services were received in the emergency room triage department.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 waive the copayment for the emergency room visit provided August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on August 17, 2019 by out of network provider.You asked the Plan to pay for the oxygen concentrator. You say that the enrollee does not want to be referred to a different DME company.The Plan denied your request. The Plan says this service was not authorized.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 has network providers available who can provide 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 oxygen concentrator provided on August 17, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Dual-Energy X-Ray Absorptiometry (DEXA) scan provided on February 25, 2019 by out of network provider.You asked the Plan to pay for DEXA scan. You say that you received 2 letters authorizing you to have this test done.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and this service was available within the Plan network.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 has network providers available who can provide 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 Dual-Energy X-Ray Absorptiometry (DEXA) scan provided on February 25, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core build up (D2950) for tooth # 10 provided on October 9, 2019.You asked the Plan to pay forthe dental service. You say that most of the dental work that you received from the provider needs to be redone.The Plan denied your request. The Plan says the frequency limit of 1 core buildup per tooth every 2 years has been exceeded.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 and core build up is listed as a covered service, the frequency limit of one procedure per tooth every 2 years has been exceeded. The record shows that you last received core build up for tooth # 10 on July 26, 2018.Therefore, we decided that the Plan does not have to pay forthe core build up (D2950) for tooth # 10 provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased from the practice on February 6, 2019.You asked the Plan to pay for the eyeglasses. You say that you went to your physician and got your eye exam and then to the practice to get the eyeglasses. You were unaware that they were not in network and thought this would be covered.The Plan denied your request. The Plan says for covered vision services you must use an in-network provider.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 when The plan covers up to $200 every 12 months for eyewear, the practice is not a provider. We looked at the file and the Plan's rules. eyewear purchased from a non-participating provider is not covered. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met.Therefore, we decided that the Plan does not have to pay for the eyeglasses purchased from the practice on February 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pay forcomplete denture -mandibular (D5120) and complete denture -maxillary  (D5110) provided on July 26, 2019.You asked the Plan to pay forthe dental services. You say that you were unaware the services were not going to be covered.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, it is not covered.Therefore, we decided that the Plan does not have to pay forcomplete denture -mandibular (D5120) and complete denture -maxillary  (D5110) provided on July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intravenous moderate (conscious) sedation/analgesia provided on August 5, 2019.You asked the Plan to pay forthese services. You say that Novocain or other pain numbing products are very ineffective on you.The Plan denied your request. The Plan says that this is not a covered 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.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 forthe intravenous moderate (conscious) sedation/analgesia provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment because you saw a different surgeon from the same physician group. You say that your surgeon was out of town. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the provider is a specialist.
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 specialist office visit provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 11, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were charged a copayment for an annual prostate cancer screen. You say that a copayment should not apply to an annual test when no other conditions were treated. The Plan denied your request. The Plan says the copayment 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 $25 copayment for an in-network specialist office visit. Covered services include consultation, diagnosis and treatment by a specialist. You have been asked to pay a $25 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that a rectal exam was performed and your medications and urinary tract health were discussed during the office 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 office visit provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit on April 10, 2019.You asked the Plan to reduce the copayment for the urgent care visit. You say that the urgent care facility was in-network and it was not your choice to be treated by an out-of-network doctor. You say you should be charged the in-network amount. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for urgently needed services at out-of-network primary care physician's office, specialist's office, or urgent care center. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows that you were treated at an out-of-network urgent care facility by an out-of-network doctor.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the urgent care visit on April 10,2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 17, 2018 through October 19, 2018.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 17, 2018 through October 19, 2018.