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

We decided that the Plan does not have to waive the copayment for the telehealth visit you had with an otolaryngologist on March 3, 2021.
You asked the Plan to waive the copayment for the telehealth visit. You say that because this was a telehealth visit, this copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for visits or consultations with a specialist, including telehealth services. You have been asked to pay a $40 copayment for the telehealth 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 copayment for the telehealth visit you had with an otolaryngologist on March 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Avastin injection you received on
March 3, 2021.
You asked the Plan to waive the coinsurance for the Avastin injection. You say that you believe you were
billed twice for one injection. You say that you were charged $150 for one injection and over $2500 for the
second injection. You want to know the reason for the double billing. The Plan denied your request. The Plan
says you were charged this coinsurance 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 Medicare Part B drugs.
Records show that you received a total of 170 units of Avastin. The provider from whom you received this
drug broke these units into two line items on the bill, which is why there are two separate charges (even though
you may have received only one injection of Avastin.) The total allowed amount for the 170 units of this drug
is $12776.69.
You have been asked to pay 20% coinsurance for the Avastin injection, for a total coinsurance of $2555.33 for
the Avastin. The Avastin injection falls within the Medicare Part B 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 coinsurance for the Avastin injection you received on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the extremity study you had with a diagnostic radiology specialist on April 1, 2021.
You asked the Plan to waive the copayment for the extremity study. You say that you do not feel as though you should pay this copayment because it was ordered by the Plan. You also said that you believe you had this test in the past with your cardiologist. The Plan denied your request. The Plan says that you were charged this copayment 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 $40 copayment for diagnostic tests in a specialist's office.
You have been asked to pay a $40 copayment for the extremity study. You had this test in a specialist's office, so it falls within the diagnostic tests in a specialist's office benefit category. This copayment applies regardless of the reason for the test. 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 extremity study you had with a diagnostic radiology specialist on April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, IV tubing extension set, and infection control supplies represented by codes 99072, S1015, and S8301 provided on February 24, 2021.
You asked the Plan to pay for codes 99072, S1015, and S8301. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. We find that the additional supplies are not
supported as billed. Specifically, the additional supplies are coded as 99072. Code 99072 has a status code of
"B" under the Medicare Physician's Fee Schedule Database (MPFSDB) and no separate payment is made for
this code under the fee schedule as payment is bundled into the payment for the services to which this code is
incident to. We also find that the IV tubing extension set and infection control supplies with codes S1015 and
S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not
valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services.
Therefore, we decided that the Plan does not have to pay for the additional supplies, IV tubing extension set,
and infection control supplies represented by codes 99072, S1015, and S8301 provided on February 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health services provided from November 24, 2020, to November 28, 2020.
You asked the Plan to waive the copayment for the inpatient mental health services. You say that your husband's death and delirium were caused by anesthesia, so you do not believe you should have to pay this copayment. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $900 copayment per stay for days 1-150 for inpatient mental health care. The enrollee has been asked to pay a $900 copayment per stay for days 1-150 for the inpatient mental health services. This copayment applies regardless of the reason for the inpatient mental health stay. 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 copayment for inpatient mental health services provided from November 24, 2020, to November 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 14, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that the referring provider is also out-of-network.
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 lab work provided on
April 14, 2021 by an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the wound debridement procedure you had at an outpatient hospital facility on November 13, 2020.
You asked the Plan to reduce the copayment for the wound debridement procedure. You say that you though your copayment would only be $35. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for surgery or procedures at an outpatient hospital facility. You have been asked to pay a $250 copayment for the wound debridement procedure. The wound debridement procedure falls within the surgery or procedures at an outpatient hospital facility 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 reduce the copayment for the wound debridement procedure you had at an outpatient hospital facility on November 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and comprehensive oral evaluation - new or established patient (D0150) provided April 27, 2021.
You asked the Plan to pay for the complete series of intraoral x-rays and comprehensive oral exam. You say that you were told that your benefits start over at the beginning of the year and you have not yet received a booklet explaining the time limitations. The Plan denied your request. The Plan says the service are covered benefits, but you have exceeded frequency limitations and therefore they are not 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. The Plan covers the complete series of intraoral x-rays and comprehensive oral exam when the services once every three plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral
exam and complete series of intraoral x-rays were previously covered on July 14, 2020. Based on this information, we determined that the Plan's frequency limit for the intraoral x-rays and comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) and comprehensive oral evaluation - new or established patient (D0150) provided April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotic
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy services provided on
February 11, 2021.
You asked the Plan to pay for medical nutrition therapy services. You say that the service was medically necessary. The Plan denied your request. The Plan says medical nutrition therapy is covered by Medicare only for diabetes and renal disease.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy services provided on February 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on
March 6, 2021.
You asked the Plan to pay for the ambulance response and treatment, no transport. You say that when the
Emergency Medical Technicians (EMT) arrived they took vitals. You say that there was a brief discussion with
the EMT's about which hospital to take the enrollee to, however the EMT's advised that they could not treat
her on the way to the hospital and it would be expensive. The Plan denied your request. The Plan says the
ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays
for the services provided.
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 March 6, 2021. 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 ambulance response and treatment, no transport
provided on March 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a gym membership for the
2020 benefit year.
You asked the Plan to reimburse you for the gym membership. You say that you have not been reimbursed for
the 2020 benefit year. The Plan denied your request. The Plan says that the Plan does not have valid proof of
payment for additional reimbursement. We have already reimbursed you for the 2020 benefit year.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan does not have valid proof of payment for
additional reimbursement, and the Plan has reimbursed you for the 2020 benefit year. Therefore, we decided
that the Plan does not have to reimburse you an additional amount for a gym membership for the 2020 benefit year.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 16, 2021 to March 18, 2021.
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the rules say the Type of Bill is a required data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 16, 2021 to March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for speech therapy services received from January 4, 2021, to February 19, 2021.
You asked the Plan to waive the copayments for the speech therapy services. You say that you were told there would be no copayment for this service. The Plan denied your request. The Plan says these copayments were charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $35 copayment per visit for speech therapy services. The enrollee has been asked to pay a $35 copayment per visit for the speech therapy services. 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 copayments for speech therapy services received from January 4, 2021, to February 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on December 14, 2020.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records to show the necessity of the service. The Plan denied your request. The Plan says that the denial of payment for this testing is correct.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for drug testing provided on December 14, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eyeglass fitting (92340) provided April 2, 2021.
You asked the Plan to pay for the eyeglass fitting. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for an eyeglass fitting (92340) provided April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and lab test provided on February 5, 2020 by
an out-of-network (OON) provider.
You asked the Plan to pay for office visit and lab test. You say that you believe that you are contracted with the
Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because
this provider is out-of-network with the Plan and 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 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 an office visit and lab test provided on February 5, 2020 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on March 28, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were unaware that you would owe these charges. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per trip for ambulance services. You have been asked to pay a $250 copayment per trip for the ambulance services. 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 ambulance services you received on March 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (20605) provided January 8, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 20605 is not supported in the medical record. Specifically, review indicates that surgery procedure 64616 has a global surgery period of 10 days. This procedure was billed on January 7, 2021. CPT 20605 is included in the global surgery package. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (20605) provided January 8, 2021