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

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October 12, 2020.
You asked the Plan to waive the copayment for the medical eye exam. You say that you expected to have a routine eye exam but had to pay a $20 copayment for a significant diagnosis and treatment that were not discussed during your visit. The Plan denied your request. The Plan says you have been asked to pay 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 for physician services to diagnose and treat diseases and conditions of the eye. You have been asked to pay a $20 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows a diagnosis of keratoconjunctivitis sicca and treatment options were discussed. 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 medical eye exam provided on October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoes provided by an OON provider.

You asked the Plan to pay for the shoes. You say that you were unaware that you couldn't use Amazon. The
Plan denied your request. The Plan says you received services from an out-of-network provider and there was
no emergency, urgent care, or pre-approval.

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 the shoes provided by an
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
September 9, 2020.
You asked the Plan to pay for the subsequent nursing facility care. 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 subsequent nursing facility care provided on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bone implant removal provided on October 30, 2020.
You asked the Plan to waive the copayment for the bone implant removal. You say that you had to go back for another surgery because you couldn't tolerate the pain. You say that you shouldn't have to pay another $300. 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 $300 copayment for Medicare-covered surgery, provided in an outpatient hospital or an ambulatory surgical center.
You have been asked to pay a $300 copayment for the bone implant removal. The bone implant 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 the bone implant removal provided on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the laboratory services provided on March 25, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic drug injection dental (D9610) consultation,
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided
November 5, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing because you cannot afford to
pay for this yourself. You have extreme anxiety which, you are on Fluoxetine medication for. This is why you
opted for this form of sedation. The Plan denied your request. The Plan says the 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 any service not listed under the covered dental procedures 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
therapeutic drug injection dental (D9610) consultation, diagnostic service provided by dentist or physician
other than requesting dentist or physician (D9310) provided November 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 30, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics.
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 September 30, 2020. 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 provided on September 30,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on September 18, 2020.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because your
chiropractic services have always been covered in the past. The Plan denied your request. The Plan says only
the manual manipulation is covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for the office visit (99213) provided on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the power wheelchair and elevating leg
rests provided on May 29, 2020.
You asked the Plan to waive the coinsurance for the power wheelchair and elevating leg rests. You say that you
were informed the wheelchair was over 5 years old so insurance would pay to replace it. The Plan denied your
request. The Plan says the coinsurance 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 20% of
the plan-allowed amount for Medicare-covered durable medical equipment from an in-network provider.
You have been asked to pay a total of $93.99 for the power wheelchair and elevating leg rests.
Service Allowed Amount Coinsurance Member Liability
Power Wheelchair $454.72 20% $90.94
Elevating Leg Rests $15.24 20% $3.05
TOTAL: $93.99
The power wheelchair and elevating leg rests fall within the "Durable medical equipment (DME) and related
supplies" benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the power wheelchair and
elevating leg rests provided on May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September
30, 2020.
You asked the Plan to pay for the dental service. You say that the periodontal maintenance was necessary. The
Plan denied your request. The Plan says periodontal maintenance is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance (D4910) provided on September 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on June 24, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that they check for free every two years so you shouldn't be charged for having a problem checked. You say that you don't want to be charged for this. 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 $210 for each Medicare-covered outpatient admission to an ambulatory surgical center. You have been asked to pay a $210 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was performed due to a change in bowel habits and constipation, which is considered diagnostic in nature. 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 colonoscopy provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the biopsy or the specialist office visit provided on August 19, 2020 and August 26, 2020.
You asked the Plan to waive the copayments for the biopsy and the specialist office visit. You say that you were told there would be no copayment for the procedure and no copayment for the follow-up visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 copayment for the biopsy and a $35 copayment for the specialist office visit. The biopsy and the specialist office visit fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which states a copayment will be waived for a surgical follow-up visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the biopsy or the specialist office visit provided on August 19, 2020 and August 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee's needs are custodial.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. Continued SNF services beyond March 14, 2021, were requested. 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 continued services. Our physician reviewer found that the enrollee is at an independent assist level with sitting up and lying down, moderate assist for bed to chair transfers, and standby assist for ambulation. The enrollee does not have documented skilled nursing or therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from July 7, 2020, at 5:46 AM, to July 9, 2020, at 9:00 PM.
You asked the Plan to pay for the inpatient services. You say that the care provided was appropriate and reasonable. The Plan denied your request. The Plan says the enrollee's emergent status had stabilized.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 the inpatient services. Our physician reviewer found that by 5:45 p.m. on July 7, 2020, the enrollee was stable for ambulance transport with monitoring. He was afebrile with no complaints of cardiopulmonary distress. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from July 7, 2020, at 5:46 AM, to July 9, 2020, at 9:00 PM.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the four Abutment supported porcelain fused to metal crowns provided on July 31, 2020 and August 27, 2020.
You asked the Plan to reimburse you for the crowns. You say that you were told all crowns are covered. The Plan denied your request. The Plan says the crowns are non-covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the four Abutment supported porcelain fused to metal crowns provided on July 31, 2020 and August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient specialist visit.
You asked the Plan to waive the copayment for the outpatient specialist visit. You say that this visit was in relation to a surgery, therefore the copayment should be waived. The Plan denied your request. The Plan says the office visit at issue was provided more than 90 days after your surgery, therefore falls outside of the global 90-day period for visits covered in relation to the surgery.
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 outpatient hospital services. You have been asked to pay a $50 copayment for the outpatient specialist visit. The outpatient specialist visit falls within the outpatient hospital services benefit category. The office visit at issue was provided more than 90 days after your surgery on July 14, 2020. This means that a separate copayment applies for this office visit, and 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 outpatient specialist visit.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070) provided on October 7, 2020.
You asked the Plan to pay for portable x-ray services. You say that these are Medicare-covered services. The Plan denied your request. The Plan says these services are subject to consolidated billing.
The Plan must follow Medicare rules. Medicare rules say that that when a SNF resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component (representing the physician's interpretation of the test results) is a separately billable physician service under Part B. By contrast, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing (the SNF "bundling" requirement for services furnished to the SNF's Part A residents), and must be included on the SNF's Part A bill for the resident's covered stay (Bill Type 21x) rather than being billed separately under Part B. We looked at the file and Medicare rules. The services at issue were provided to an SNF resident and cannot be billed separately from the SNF stay. Based on this information, we decided that Medicare rules for coverage of
portable x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray services (Q0092, R0070) provided on October 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on November
19, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that the at-home physical therapist
called the ambulance for you. You say you did not want to go back to the hospital. The Plan denied your
request. The Plan says you have been asked to pay 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 $200
copayment for each in-network and out-of-network separate Medicare-covered, one-way ambulance service.
You have been asked to pay a $200 copayment for the ambulance ride. The ambulance ride falls within the
"Ambulance 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
ambulance ride provided on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clasping materials replacement provided on October 26,
2020.
You asked the Plan to pay for the clasping materials replacement. You say that you were told insurance would
pay 25% for major dental services received out-of-network. You say that this service was absolutely necessary.
The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
clasping materials replacement provided on October 26, 2020.