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

We decided that the Plan does not have to waive the deductible for the laboratory services provided on January 9, 2020.
You asked the Plan to waive the deductible for the laboratory services. You say that you believe you have been billed incorrectly. 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. Your contract with the Plan says that there is a $198 deductible that applies towards in-network laboratory services. The laboratory services you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible that applies towards in-network laboratory services. This cost sharing is a contractual obligation that had not been met at the time the laboratory services were received on January 9, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on January 9, 2020.
Your complaint about the fraudulent billing is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) and extraction (D7210) provided January 7, 2020.
You asked the Plan to pay for the dental services. You say that you were advised that you could go to any licensed dentist in the U.S. and you would receive $850 reimbursement toward any preventive and/or comprehensive dental work. The Plan denied your request. The Plan says if you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for limited oral exam (D0140) and extraction (D7210) provided January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmology eye examination provided on January 31, 2020.
You asked the Plan to waive the copayment for eye exam. You say that this examination was supposed to be a preventive service and you are appealing this copayment. 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 $40 copayment for diagnostic eye exam. This visit was provided for a non-routine diagnosis; therefore, the diagnostic eye exam copayment applies to this claim. You have been asked to pay $40 copayment for eye exam. Eye exam falls within the Vision 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 ophthalmology eye examination provided on January 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on June 5, 2019.
You asked the Plan to pay for the definitive drug testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says the order does not clearly indicate the drugs to be tested.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating physician. In this case, the file has a copy showing the provider's custom panel. The order form indicates an order for panel code R093. There is no documentation to support that this code is for requesting the custom panel or what drugs would be included on that panel. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on June 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on March 11, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you do not recall paying for blood tests in the past. 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 $20 copayment per visit for laboratory tests, non-radiological tests, flat film x-rays, and ultrasounds. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the laboratory work.
You have been asked to pay a $12.05 copayment for the laboratory work. The laboratory work 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 laboratory work provided on March 11, 2020.
Our decision is only about the March 11, 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that thePlan does not have to waive the copaymentfor the inpatient hospital care provided January 22, 2020 to February 5, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the inpatient hospital care provided.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 $275 copayment per day, for days 1-6 and a $0 copayment per day, for days 7-90, for each Medicare-covered hospital stay. You have been asked to pay a $1,650 copayment ($275 copayment x 6 days) for inpatient hospital care. This means that you have been asked to pay the correct amount based onyour 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 copaymentfor the inpatient hospital care provided January 22, 2020 to February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive thecopayment forprophylaxis, cleaning (D1110) comprehensive oral exam (D0150) and intraoral complete series x-rays (D0210) provided February 17, 2020.You asked the Plan to waive the copayment forthe dental services. You say that you are appealingthis denial because you called member services and was told that the provider is a participating provider.The Plan denied your request. The Plan says the copayments were applied correctly the plan's benefits chart on pages 96 and 97.The rules say aplan 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 the copayment amounts that is listed on the Routine Dental Benefits Procedure Chart. You have been asked to pay $41. The copayment amounts that are listed on the Routine Dental Benefits Procedure Chart shows that there is $16 copayment for D0150 $5 copayment for D0210 and $20 copayment for D1110. Codes D1208 and D0431 are not covered under the plan benefits and was refunded to you by the provider. The dental services fall within the Dental services, routine 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 forprophylaxis, cleaning (D1110) comprehensive oral exam (D0150) and intraoral complete series x-rays (D0210) provided February 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance angiogram (MRA) of the 
head/neck. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRA is covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a three year history of 
headaches. Prior magnetic resonance imaging (MRI) and MRA studies showed that the left trigeminal nerve 
was in contact with a cerebellar artery and chronic microvascular ischemic changes in the brain were noted. 
Recent documentation does not suggest a significant shift in symptoms or physical findings or a planned 
procedure to justify repeat imaging. The MRA is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance angiogram (MRA) of the head/neck.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on February 19, 2020. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 February 19, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cystourethroscopy provided on January 24, 2020.You asked the Plan to waive the copayment forthe cystourethroscopy. You say that this was a follow-up procedure to a surgery. You say you would like the copayment waived because you are unable to pay such large copayments. 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 $400 copayment for an outpatient hospital facility. You have been asked to pay a $400 copayment for the cystourethroscopy. The cystourethroscopy falls within the an "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.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 cystourethroscopy providedon January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that 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. 
 
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 
physician?s services. 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 physician's services provided on March 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran (Office visit (99214), Neuromuscular junction testing (95937), and Nerve conduction studies (95913) provided March 3, 2020.You asked the Plan to waive the copayment forthe office visit, neuromuscular testing, and nerve conduction studies. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct copayments were 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 $30 copayment for specialist visits, a $20 copayment for diagnostic services and a $100 copayment for diagnostic radiology other than X-rays. You have been asked to pay a $30 copayment for a specialist visit (the office visit), a $20 copayment for a diagnostic service (neuromuscular junction testing) and a $100 copayment for diagnostic radiology (nerve conduction studies) for a total cost share of $150. 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 foran (Office visit (99214), Neuromuscular junction testing (95937), and Nerve conduction studies (95913) provided March 3, 2020
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound of the breast (76641) 
provided March 13, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment is excessive and 
should be waived. The Plan denied your request. The Plan says the correct copayment according to the plan 
contract was 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 $45 
copayment for Radiology Services.  
 
You have been asked to pay a $45 copayment for the ultrasound. The ultrasound falls within the Radiology 
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 an ultrasound of the breast 
(76641) provided March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hip surgery to be provided at the requested hospital. 
 
You asked the Plan to pay for the hip surgery. You say that there are no hip surgeons that accept your plan in 
your area. You say you were advised to go to the hospital where three of your relatives had successful surgery. 
The Plan denied your request. The Plan says you must receive care from in-network providers with the 
exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care 
cannot be provided with an in-network provider, which requires prior authorization from the plan. 
 
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 pre-approve 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve hip 
surgery to be provided at the requested hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for the omalizumab treatment provided on 
December 27, 2019. 
 
You asked the Plan to waive the charges for the omalizumab injection. You say that you were told there would 
be no cost for this medication. The Plan denied your request. The Plan says the documentation does not show 
that you were misinformed about coverage for this medication. Your EOC clearly states that enrollees must pay 
20% coinsurance for Part B covered drugs. 
 
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 Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for the omalizumab injection. The omalizumab 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 charges for 
the omalizumab treatment provided on December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 6, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 and the referring provider are not network providers with the Plan. The Plan 
did not pre-approve the laboratory services. 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 laboratory services provided on 
September 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHydroxychloroquine.You asked the Plan to pre-approveHydroxychloroquine. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveHydroxychloroquine.Benefits for Hydroxychloroquinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, anterior tooth, tooth 25 (D3310) and 
periradicular surgery without apicoectomy, tooth 25 (D3427) provided March 2, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were given the options to have the 
procedures done and save the tooth, have it pulled and have a transplant done or let it decay and fall out which 
would cause unbearable pain. The Plan denied your request. The Plan says these services are not covered under 
the plan benefits. 
 
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. The health plan contract says 
that services not on the list of approved services are not covered.  
 
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 for 
endodontic therapy, anterior tooth, tooth 25 (D3310) and periradicular surgery without apicoectomy, tooth 25 
(D3427) provided March 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground 
mileage (A0425) provided March 18, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you feel that the ambulance service should 
have been covered because you had received prior approval to get care at the facility. The Plan denied your 
request. The Plan says the ambulance service was billed for an origin and/or destination that is not covered. 
Transportation to a physician office is not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctor's office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. 
Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and 
ground mileage (A0425) provided March 18, 2020.