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

We decided that the Plan does not have to pay for the dental services you received on August 22, 2019.
You asked the Plan to pay the dental services. The Plan denied your request. The Plan says the provider is not a participating provider under your 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 services may require a high cost share when provided by an out-of-network provider. The requested provider is not contracted under your plan. This means that the provider can bill you for additional costs when the charges are more than the maximum benefit amount covered by the plan. The plan paid up to the contracted amount of $74. You are responsible for the excess amount billed by the provider. Therefore, we decided that the Plan does not have to pay for the dental services you received on August 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on June 4, 2019.
You asked the Plan to pay for the hearing aids. You say that you are appealing for reconsideration of the denied
charges. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health
Plan. The Plan states you contacted the Plan on April 25, 2019 and was advised that there was no coverage for
hearing aids.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these
types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids
purchased on June 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.You asked the Plan to pay for the paramedic intercept services. You say that an ambulance was called for you to be transported. You say that you had no control over what paramedic provided your care.The Plan denied your request. The Plan says this item is not a covered benefit.The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the services are furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided at "the provider"  on March 29, 2019.You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you feel that the services received do not warrant a copayment.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 $40 copayment for outpatient rehabilitation services. You have been asked to pay a $40 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided at "the provider" on March 29, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on August 19, 2019.You asked the Plan to pay for the emergency room services. You say that the documentation provided supports the services in dispute.The Plan denied your request. The Plan says they have paid for these services under a separate claim.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The records show that the plan paid for emergency room services provided on August 19, 2019. The records show that these services were paid for.Therefore, we decided that the Plan does not have to pay for emergency room services provided on August 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hand x-ray provided on August 20,
2019.
You asked the Plan to waive the copayment for the hand x-ray. You say that sometimes things happen if the
wrong code is used. You say that the Plan should have paid this in full. 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 $50
copayment for basic radiological services at an in-network specialist's office.
You have been asked to pay $37.27, which is less than the standard $50 copayment for the hand x-ray. The
hand x-ray 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 the hand x-ray provided on August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the bone graft (D7295), the drugs or medicaments (D9630 x 2), and the implant provided on January 25, 2019.You asked the Plan to reimburse you for the dental services. You say that you have medical conditions that required you to have teeth pulled. You say that you were in extreme pain. You also say that if you did not have the teeth extracted, the pain would have exacerbated your Multiple Sclerosis symptoms.The Plan denied your request. The Plan says the services that you received are not listed as covered services.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 bone graft, drugs or medicaments, and implant are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you for the bone graft (D7295), the drugs or medicaments (D9630 x 2), and the implant provided on January 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a screening mammography provided on
September 4, 2019.
You asked the Plan to waive the coinsurance for the screening mammography. You say that you went to an innetwork
facility and had no way of knowing the radiologist was out-of-network. The Plan denied your request.
The Plan says per the EOC, breast cancer screenings provided out-of-network have a 50% coinsurance of the
total cost for Medicare-covered services.
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 50%
coinsurance for Breast cancer screening (mammograms).
You have been asked to pay 50% coinsurance for the screening mammography. The screening mammography
falls within the Breast cancer screening (mammograms) 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 a screening mammography provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the right hearing aid provided on August 23, 2018.You asked the Plan to pay for the right hearing aid. You say that the plan has not paid for hearing aids for you.The Plan denied your request. The Plan says that they have paid up to the benefit allowance.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to $800 every three years for hearing aids.We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum quarterly benefit of $800 for hearing aids. There is no provision in the contract which would require the plan to approve more than this amount.Therefore, we decided that the Plan does not have to pay for the right hearing aid provided on August 23, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lab services provided by on July 31, 2019.You asked the Plan to waive the deductible for lab services. You say that 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. Your contract with the Plan says that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received lab services provided on July 31, 2019. The record shows that you had only paid $110.38 toward the $300 deductible. Therefore, you are responsible to pay the allowed amount of $110.02. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a$300 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time lab services were received on July 31, 2019.Therefore, we decided that the Plan does not have to waive the deductible for lab services provided on July 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay Gradient Compression Stockings (A6531) provided July 10, 2019.
You asked the Plan to pay the compression stockings. You say that the compression stockings should be covered. The Plan denied your request. The Plan says they have contacted the provider who confirmed they do not participate in Medicare. They only accept private payment.
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. This provider is not certified to participate in the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay Gradient Compression Stockings (A6531) provided July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for extracapsular cataract removal provided by the practice on June 27, 2019.You asked the Plan to waive the copayment for extracapsular cataract removal. You say 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 $300 copayment for surgery services provided in an ambulatory surgical center. You have been asked to pay a $300 copayment for extracapsular cataract removal. Extracapsular cataract removal 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 extracapsular cataract removal provided by the practice on June 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 22, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services rendered to you by on September 4, 2019.

You asked the Plan to waive the coinsurance for these services. You say that you had pain in your foot and should not be liable because the tests should not have been ordered. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for services you get in the outpatient department of a hospital. 

Review of the file shows that you received outpatient hospital services on September 4, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the services you get in the outpatient department of a hospital 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 outpatient hospital services rendered to you on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 24, 2019.You asked the Plan to waive the copayment for laboratory services. You say that the provider is in-network. You say that you had no way of knowing the lab was not in-network.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 $70 copayment for lab services at an in-network outpatient hospital. You have been asked to pay a $70 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the claim was processed as in-network. 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 services provided on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided to the enrollee by an in-network provider, from May 16, 2019 through July 16, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you believe the enrollee is being balance billed by the plan.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC 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). Review of the file show that the enrollee received DME provided by an in-network provider from May 16, 2019 through July 16, 2019. Therefore, the enrollee is asked to pay 20% coinsurance for the DME. 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 coinsurance for the DME provided to the enrollee by an in-network provider, from May 16, 2019 through July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on April 5, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on April 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe services provided to "the beneficiary" on February 2, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says that the claim was not filed within the 180 day limit.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.ThePlan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Medicare rules state that claims for services must be filed no later than the close of the period ending one calendar year after the date of service. The plan denied the services for being submitted more than 180 days after the date of service. The records do not show that the claim was filed more than one year after the date of service. The plan has not substantiated itsdenial with regard to the Medicare rules for timely filing.Therefore, we decided that the Plan has to pay forthe services provided to "the beneficiary" on February 2, 2019.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 toopen the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on July 25, 2019.You asked the Plan to waive the copayment forthe breast ultrasound. You say that you should not have a copayment for a mammogram.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 $100 copayment for diagnostic radiology. You have been asked to pay $64.27, which is less than the standard $100 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you had a breast ultrasound in addition to the screening mammogram. 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 breast ultrasound provided on July 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ear molds provided.
You asked the Plan to reimburse you for the ear molds. You say that the Plan should reimburse you. The Plan denied your request. The Plan says ear molds are not a covered Hearing Benefit.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ear molds have not been met. Therefore, we decided that the Plan does not have to reimburse you for the ear molds provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
Review of the file shows that no progress notes from the ordering provider were provided to support the
validity of the testing provided. The documentation did not support that the testing at issue in this appeal was
not requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.
Therefore, we decided that the Plan does not have to pay for the laboratory testing provided.