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

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (43235) provided January 20, 2021.

You asked the Plan to waive the copayment for the outpatient procedure. You say that you were charged a $300 copay for preventive colorectal cancer exam but as per your benefits, you should not have a copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage

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 $300 copay for each Medicare covered outpatient hospital visit. 

You have been asked to pay $300 copay for the outpatient procedure. The outpatient procedure 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 the esophagogastroduodenoscopy (43235) provided January 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the posterior resin-based composite of three surfaces provided on April 1, 2021.
You asked the Plan to pay more for the resin-based composite. You say that when you were sold your current insurance you assumed the services would be covered. The Plan denied your request. The Plan says you are responsible for a total cost-share of $144.50.
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, multi-surfaces will be processed as a silver filling and you are responsible up to the contracted fee. The contract also says that you are responsible for a 50% coinsurance after your $100 deductible has been met. The record shows that you still had $12.00 remaining to meet your deductible, plus the 50% coinsurance after the deductible ($72.50), plus the difference between the allowed amounts between the resin-based composite and the silver filling ($60.00). Therefore, we decided that the Plan does not have to pay more for the posterior resin-based composite of three surfaces provided on April 1, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on December 18, 2020.
You asked the Plan to pay for the infectious agent detection. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid provided on December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided by a participating provider on January 19, 2021, to February 26, 2021.
You asked the Plan to waive the copayment for radiation therapy. You say that you cannot afford these copayments. The Plan denied your request. The Plan says the correct copayments have 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 $60 copayment for outpatient diagnostic tests/radiation therapy visits. You have been asked to pay a $60 copayment for each radiation therapy session. The total amount you are being asked to pay is $1,740 ($60 x 29 sessions = $1,740). The correct copayment has been applied to the services that were provided. Radiation therapy falls within the outpatient diagnostic tests/radiation therapy visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for radiation therapy provided by a participating provider on January 19, 2021, to February 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider from January 1, 2019, through January 30, 2019.
You asked the Plan to pay for physical therapy. You say that you were informed authorization was not needed for out-of-network therapy visits. You say that the facility is not at fault and payment should be considered due to incorrect information provided by the Plan. The Plan denied your request. The Plan says the out-of-network services were not authorized and in-network providers were available.
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 physical therapy provided by an out-of-network provider from January 1, 2019, through January 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on March 17, 2021.
You asked the Plan to waive the copayment for EKG. You say that this was a wellness visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 copayment for EKG. You have been asked to pay $10 copayment for EKG. EKG falls 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
an electrocardiogram (EKG) provided on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided by a participating provider on February 1, 2021.
You asked the Plan to waive the coinsurance for genetic testing. You say that you should not have to pay for 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 outpatient diagnostic tests/in-network/genetic testing. You have been asked to pay a 20% coinsurance of the allowed amount for genetic testing. The total allowed amount is $3,873. The total amount you are being asked to pay is $774.60 ($3,873 x 20% = $774.60). The correct coinsurance has been applied to the testing that was provided. Genetic testing falls within the outpatient
diagnostic tests/in-network/genetic testing 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 genetic testing provided by a participating provider on February 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on January 5, 2021 by an outof-
network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you were told this was in-network. The
Plan denied your request. The Plan says that this was not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. However, the contract
with the Plan says that the Plan will cover services from either in-network or out-of-network providers, as long
as the services are covered benefits and medically necessary. The Plan contract also says that enrollees don't
need to get a referral or prior authorization to get care from out-of-network providers.

The Plan has denied the service at issue on the basis of out-of-network providers requiring authorization.
However, the Plan contract specifically states that authorization is not required for out-of-network services.
Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on January 5, 2021
by an out-of-network (OON) provider.

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 the resin filling (D2330) and unspecified preventative
procedure (D1999) provided on April 13, 2021, by an out-of-network provider.
You asked the Plan to pay for the out-of-network dental care. You say that these services were necessary. The
provider also did not inform you that they were out-of-network, and they were the most accessible to you. The
Plan denied your request. The Plan says out-of-network dental care is not covered. There were other in-network
dentists who were available to provide the necessary services. In addition, an unspecified preventative
procedure is not covered by your dental benefit, regardless of the network status of the provider.
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, items or services provided out-ofnetwork
are not covered in most circumstances. 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 resin
filling (D2330) and unspecified preventative procedure (D1999) provided on April 13, 2021, by an out-ofnetwork
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that the requested facet joint injections are
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested facet joint injections.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
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 facet joint injections. Our reviewer says
that the enrollee does not meet criteria for the requested facet joint injections. Our physician reviewer found the
LCD requires Medial branch blocks leading to radiofrequency ablation (RFA). Repeat intra-articular injections
are not supported. Therefore, the request is deemed not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint injections
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received February 8, 2021 from the opt-out provider.
You asked the Plan to pay for the periodic oral evaluation. You say that the Plan should pay for the requested services. The Plan denied your request. The Plan says you must receive your care from a dental provider who participates with Medicare.
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 when they are received from a provider who has opted out of Medicare.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) received February 8, 2021 from the opt-out provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) abdomen (74181)
provided on February 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the MRI. You say that you had surgery and received an MRI and would like to
appeal the denial The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with
non-contracted providers require prior authorization before services being rendered.
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 magnetic resonance imaging (MRI) abdomen
(74181) provided on February 4, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
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 services was not filed until April 2, 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 the services provided on August 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 the insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show that it is safe and effective. 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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on March 30, 2021.
You asked the Plan to pay for the eyeglasses. You say that you have cataracts, and you believe there has been a change in your vision since receiving your previous eyeglasses. The Plan denied your request. The Plan says coverage for the eyewear benefit is once per two calendar years and you have already used the benefit during this time period.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every 2 years.
We looked at the file and the Plan's rules. The file shows that you received coverage for eyeglasses on
February 18, 2021. 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 eyeglasses provided on
March 30, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for genetic testing provided by a participating provider on January 20, 2021.

You asked the Plan to waive the coinsurance for genetic testing. You say that these charges are too high. 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 outpatient diagnostic tests/in-network/genetic testing.

You have been asked to pay a 20% coinsurance of the allowed amount for genetic testing. The total allowed amount is $2,510.21. The total amount you are being asked to pay is $502.04 ($2,510.21 x 20% = $502.04). The correct coinsurance has been applied to the genetic testing that was provided. Genetic testing falls within the outpatient diagnostic tests/in-network/genetic testing 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 genetic testing provided by a participating provider on January 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy rendered on
March 18, 2021.

You asked the Plan to waive the copayment for these services. You say that you thought this was a test, not a
surgery. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for each Medicare-covered outpatient hospital service, including outpatient surgery or procedure.

Review of the file shows that you had a diagnostic colonoscopy on March 18, 2021. You have been asked to
pay a $250 copayment for these services. These services fall within the Medicare-covered outpatient hospital
service, including outpatient surgery or procedure 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 diagnostic colonoscopy rendered on March 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for individual psychotherapy session, 60 minute (90837) provided January 29, 2021.
You asked the Plan to waive the copayment for the psychotherapy session. You say that during COVID psychotherapy was to be offered for $0.00. Please credit your account to $0.00. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $10 copayment for each Medicare covered individual therapy session for Outpatient mental health care. You have been asked to pay $10 copayment for each Medicare covered individual therapy session for the
psychotherapy session. the psychotherapy session falls 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. Therefore, we decided that the Plan does not have to waive the copayment for individual psychotherapy session, 60 minute (90837) provided January 29, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on February 1, 2020.
You asked the Plan to waive the copayment for emergency room visit. You say that the provider did not do anything for you. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $75 copayment for emergency room visit. You have been asked to pay $75 copayment for emergency room visit. Emergency room visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on February 1, 2020.