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

We decided that the Plan does not have to waive the copayment for the outpatient surgery services you received on September 10, 2019.You asked the Plan to waive the copayment. You say that you shouldn't have to pay because the previous surgeon did the surgery incorrectly.The Plan denied your request. The Plan says you are responsible for the copayment.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 outpatient surgery procedures. Review of the file shows that you received outpatient surgery services on September 10, 2019. You have been asked to pay a $250 copayment for the procedure. The 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 outpatient surgery services you received on September 10, 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 provider billed the Plan using the wrong code and is not willing to send supporting documents. You say that this is preventing the Plan from processing the claim correctly.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 June 26, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the back brace provided on January 24, 2019.You asked the Plan to waive the charges for the back brace. You say that you feel that you are being overcharged because you can find the same item online for much cheaper.The Plan denied your request. The Plan says you were provided with a covered item and the correct coinsurance has been applied. There is no basis for waiver of this charge.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 prosthetic devices, including braces with a cost of $100 or more. You have been asked to pay 20% coinsurance for the back brace. The back brace falls within the prosthetic devices, including braces with a cost of $100 or more 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 back brace provided on January 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 23, 2019 by out of network provider.You asked the Plan to pay for an office visit and lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on May 23, 2019by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on June 20, 2019.You asked the Plan to waive the coinsurance for an office visit. You say that the provider is in-network and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 30% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You had an office visit provided by an out-of-network provider,on June 20, 2019.Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The allowed amount is $194.89 and 30% of that is $58.46.You have been asked to pay the total coinsurance amount of $58.46 for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for an office visit provided on June 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forextraction of teeth 25, 26and 27 (D7210 x 3) provided on May 10, 2019.You asked the Plan to pay forthe dental services. You say that the Plan does provide coverage when teeth are removed prior to radiation and that it'snot covered after radiation.The Plan denied your request. The Plan says the service is not a covered benefit under the 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.The teeth extractions rendered by the provider were not for the purpose of preparing the jaw for radiation treatments of neoplastic disease.Therefore, we decided that the Plan does not have to pay forextraction of teeth 25, 26 and 27 (D7210 x 3) provided on May 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the x-ray provided on February 5, 2019. You asked the Plan to waive the coinsurance for the x-ray. You submitted your bill for review. 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 20% coinsurance for each visit for Medicare-covered x-rays. You have been asked to pay $8.58 which is 20% of the allowed amount for the x-ray. The allowed amount is $42.91. ($42.91 x 20% = $8.58). The 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 coinsurance for the x-ray provided on February 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound repair provided by the provider on July 30, 2019.You asked the Plan to waive the copayment for wound repair. You say that you disagree with the charges because services were provided in your doctor's office.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 $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received wound repair on July 30,2019. The provider is considered an outpatient hospital facility. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 copayment for wound repair. Wound repair falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for wound repair provided on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on May 31, 2019.You asked the Plan to waive the copayment for the laboratory work. You say that you cannot afford this copayment.  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 for Medicare-covered laboratory tests. You have been asked to pay a $20 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 May 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided on July 22, 2019 and August 6, 2019.You asked the Plan to waive the copayments for outpatient rehabilitation services. 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 $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services provided on July 22, 2019 and August 6, 2019. Therefore, you are responsible to pay a $40 copayment per each PT visit. The total amount you owe is: $80.00.You have been asked to pay the total copayment amount of $80.00 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 copayments for outpatient rehabilitation services provided at  on July 22, 2019 and August 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for retina imaging provided by the provider on September 4, 2019.You asked the Plan to waive the copayment for retina imaging. You say that this was an annual visit. You say that the same diagnostic follow-up was previously covered. 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 $75 copayment for Medicare-covered non-radiologic diagnostic procedures and tests.You have been asked to pay $42.38, which is less than the standard $75 copayment for retina imaging. Retina imaging 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 retina imaging provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 95999) provided to the enrollee on October 9, 2018.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service is bundled into another service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure".We asked our coding 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 services. Our reviewer says that the use of CPT code 95999 is not supported by the records provided. Our coding reviewer found that the medical record does not contain evidence that an unlisted neurological or neuromuscular diagnostic procedure that is not included in an existing CPT code and is eligible to be reported separately was performed during this episode of care.We looked at this coder'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 95999) provided to the enrollee on October 9, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot provided on June 5, 2019.
You asked the Plan to waive the coinsurance for the walking boot. You submitted your bill for review. You say that this is medically necessary. 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% coinsurance for durable medical equipment from an in-network provider. You have been asked to pay $56.98, which is 20% of the allowed amount for the walking boot. The allowed amount is $284.91 (20% x $284.91 = $56.98). The walking boot falls 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 walking boot provided on June 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 19, 2019 by out of network provider. You asked the Plan to pay for mental health visit. You say that you are very confused about which insurance you need to use for these services.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on August 19, 2019 by out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided from June 20, 2019 through July 18, 2019.You asked the Plan to waive the copayment for SNF care. You say that the social worker told you that you wouldn't have to be in charge of a copay due to a longer stay.The Plan denied your request. The Plan says the claims were processed accordingly with your 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). Two claims were submitted for dates of service June 20, 2019 through June 30, 2019 and July 1, 2019 through July 18, 2019. The first 20 days were covered in full. The remaining 8 applied a 50% coinsurance. 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 SNF care provided from June 20, 2019 through July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and lesion removal provided on June 5, 2019.You asked the Plan to waive the deductible for the office visit and lesion removal. You say that the services were not done. You say that if you were told your coverage would not suffice you would not have gone.The Plan denied your request. The Plan says the deductible applied correctly.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 your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for fall within the "Physician/Practitioner services, including doctor's office visits" and "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the office visit and lesion removal were received on June 5, 2019.Therefore, we decided that the Plan does not have to waive the deductible for the office visit and lesion removal provided on June 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 9, 2019 by an out of network provider. You asked the Plan to pay fortransesophageal echocardiography. You say that this service was performed for diagnostic purposes during surgery, and was requested by the surgeon due to medical necessity.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on July 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 30, 2019 at 6:52 pm through July 3, 2019.You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary.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 inpatient hospital care. Our physician reviewer found the review indicates that as of June 30, 2019 at 6:52 the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient level of care 
services. There was no documentation provided necessitating post -stabilization care services June 30, 2019 at 6:52 pm through July 3, 2019 at the non-participating Plan facility. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient 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 inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 30, 2019 at 6:52 pm through July 3, 2019.