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

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on April 9, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you didn't know who would be sent when you called 911. You say that you don't believe you owe an additional cost.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must discloseto 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 covered, one-way ambulance trip by ground or water.You have been asked to pay a $325 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 forthe ambulance transport provided on April 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from September 11, 2019 through September 13, 2019.You asked the Plan to pay foracute 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 paymentare met in this case. Our physician reviewer found the record does 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 forthe acute inpatient hospital care provided from September 11, 2019 through September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 31, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you should not be charged an additional $45 copayment because you were already charged for your outpatient procedure. 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 inclear, 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 services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. the specialist office visit falls within the "Physician/Practitioner services, including doctor's office 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 youenrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 31, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided  on October 1, 2019.
You asked the Plan to waive the copayment for wound debridement. You say that the procedure took place in a doctor's office, not an outpatient hospital facility, and you disagree with the charges. 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 $600 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record shows that you received wound debridement at an outpatient hospital facility on October 1, 2019. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $310.88, which is less than the $600 copayment. You have been asked to pay $310.88 for wound debridement. Wound debridement falls 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 wound debridement provided on October 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided by Out of Network (OON) Provider on October 3, 2019.You asked the Plan to waive the copayment for an EGD. You say that due to your health, services had to be rendered in an outpatient hospital facility. You state that you cannot afford the charges.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 $200 copayment for each outpatient hospital facility visit.You received an EGD at an outpatient hospital facility on October 3, 2019.  An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.  You have been asked to pay a $200 copayment for an EGD. An EGD falls 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 an EGD provided by Out of Network (OON) on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on October 29, 2018 by an OON provider.You asked the Plan to pay for the office visit. You say that you saw this provider because another primary doctor referred you to this provider's office.The Plan denied your request. The Plan says the rendering provider is outside of your Plan's network of providers. The Plan also says that prior authorization was not obtained.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 outpatient office visit provided on October 29, 2018 by an OON provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services provided on October 31, 2019 by an OON provider.You asked the Plan to pay for the chronic care management services. You say that the services were medically necessary.The Plan denied your request. The Plan says the service was rendered by a non-contracted provider. The Plan also says that proper authorization was not obtained by the 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 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 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 chronic care management services provided on October 31, 2019 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external infusion pump supplies (A4221).You asked the Plan to pre-approve external infusion pump supplies. You say that the items are medically necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that an external infusion pump is covered when specific criteria is 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 pre-approve external infusion pump supplies. Our reviewer says that the items are not medically necessary. Our physician reviewer found the ordered medication, ceftriaxone, is not asupport indication for an external infusion pump. Medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of external infusion pumpsupplies have not been met.Therefore, we decided that the Plan does not have to pre-approveexternal infusion pump supplies (A4221).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on August 26, 2019.You asked the Plan to pay for these drugs. You say that these drugs should be covered under Part D.The Plan denied your request. The Plan says that these drugs are not covered under your Part B plan.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 pay forthe self-administered drugs provided on August 26, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient behavioral health admission.You asked the Planto pre-approveinpatient behavioral health admission. You say that the services are necessary.The Plan denied your request. The Plan says the enrollee has exceeded the 190 day lifetime limit for inpatient services in a psychiatric hospital. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that payment may not be made for more than a total of 190 days of inpatient psychiatric hospital services during the patient's lifetime.We looked at the file and Medicare rules. Specifically, the enrollee's benefit maximum has been exhausted. Based on this information, we decided that Medicare rules for coverage of inpatient behavioral health admission have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient behavioral health admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 29, 2019 by an OON provider.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the enrollee went to a non-contracted provider without referral from the Plan or her primary care physician. The Plan also says the non-contracted provider referred the enrollee to the OON laboratory.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 laboratory services provided on April 29, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the CMT provided on September 11, 2019 by an OON provider.
You asked the Plan to pay for the CMT. You say that you understand you were unclear about the process for being seen by a chiropractor. The Plan denied your request. The Plan says you self-referred to an OON provider. The Plan also says that you did not obtain a 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 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 CMT provided on September 11, 2019 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 7, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on August 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered to you on October 17, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.The provider submitted a claim for procedure code 99285 (ER services) under claim number 820193000002438. The Plan previously paid for this code for the date of service at issue under claim number 820192980220998. The Plan states that you have no member responsibility for this claim.Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered to you on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Gel-One injection provided on May 14, 2019.You asked the Plan to waive the coinsurance forthe injection. You say that you want the provider to cancel the charge or the plan to pay the coinsurance.The Plan denied your request. The Plan says that cost-sharing is a contractual obligation and cannot be waived.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 Medicare Part B Prescription Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls 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 coinsurance forthe Gel-One injection provided on May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for the physician services. You say that you were advised that the Plan covered home care through health plan. You also say that the provider agreed to coordinate with the Doctors within the network who have extensive knowledge of your issues.The Plan denied your request. The Plan says you were not referred to this provider for the services. The Plan says the services could have been provided in network. The Plan also says there was no attempt made to obtain prior authorization for the service.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 noexception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the office visit provided on August 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 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 medical services provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe clinic visit (G0463) and laboratory services (80047 and 83880) provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay fora clinic visit and laboratory services. You say that this was a follow up to a previous visit.The Plan denied your request. The Plan says these services were 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 topay 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 forthe clinic visit (G0463) and laboratory services (80047 and 83880) provided on September 30, 2019 by an out of network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation services (90792) provided on July 2, 2019.You asked the Plan to waive the copayment for the psychiatric diagnostic evaluation services (90792). You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received outpatient mental health care on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 Outpatient mental health care. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a psychiatric diagnostic evaluation on July 2, 2019. You have been asked to pay a $40 copayment for the psychiatric diagnostic evaluation services (90792). The psychiatric diagnostic evaluation services (90792) fall within the Outpatient mental health 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. Health plans are not required to waive this cost sharing when there is dissatisfaction with the quality of care received.Therefore, we decided that the Plan does not have to waive the copayment for the psychiatric diagnostic evaluation services (90792) provided on July 2, 2019.