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

We decided that the Plan does not have to pay for the dental services received from an out of network provider on September 9, 2020.
You asked the Plan to pay for the dental services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are 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. Review of the file shows that you received services from an out of network provider. Dental services are only covered when provided by network providers. Therefore, we decided that the Plan does not have to pay for the dental services received from an out of network provider on September 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) provided on February 24, 2020.
You asked the Plan to waive the copayment for the head and neck CT (70486). You say that you do not agree with the copayment. 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 $125 copayment for outpatient diagnostic tests. You have been asked to pay a $122.53 copayment for the head and neck CT (70486). The head and neck CT (70486) falls within the outpatient diagnostic tests benefit category. The allowed amount is $122.53. This means that you have been asked to pay less than your copayment 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 computed tomography (CT) provided on February 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2019, by an OON provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that these medically necessary services were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
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 October 30, 2019, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound study provided on July 30, 2020.
You asked the Plan to waive the deductible for an ultrasound study. You say that you received the test due to the results of a faulty device. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $290 deductible for outpatient diagnostic tests and therapeutic services and supplies. You received an ultrasound study on July 30, 2020. The record shows that you had only paid $10.06 toward the $290 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $90.96. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time an ultrasound study was received on July 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound study provided on July 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded G0480, 83789, 80299, and 82542 provided on October 30, 2019.
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 billed are not supported by the documentation.
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 codes G0480, 83789, 80299, and 82542 are not supported in the medical record. Specifically, there is no clinical rationale for the definitive urine drug testing documentation in the medical record; therefore, code A0480 is not supported. In addition, presumptive and definitive urine drug testing does not include 83789, 80299 and 82542. Therefore, these services are not payable. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded G0480, 83789, 80299, and 82542 provided on October 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from July 2, 2020, to July 22, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this claim was billed with an invalid type of bill for a non-participating Home Health provider.
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, this claim cannot be paid as billed due to an issue with the type of bill code reported. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from July 2, 2020, to July 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on March 2, 2020, to September 7, 2020.
You asked the Plan to waive the copayment for lab work. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been 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 outpatient diagnostic tests/lab services at outpatient hospital facility. You have been asked to pay less than a $30 copayment for each lab work. The total amount you are being asked to pay is $530.98 which is less than your total copayment amount of $690 ($30 copayment x 23 lab tests = $690). Lab work falls within the outpatient diagnostic tests/lab services at 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 waive the copayment for lab work provided by a participating provider on March 2, 2020, to September 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray services provided to the enrollee on August 14, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was no network deficiency for these services.
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 portable x-ray services provided to the enrollee on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a CT scan and myocardial perfusion imaging provided on August 21, 2020, and September 3, 2020.
You asked the Plan to waive the copayments for a CT scan and myocardial perfusion imaging. You say that the enrollee cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $250 copayment for diagnostic radiology. The enrollee received a CT scan on August 21, 2020. Therefore, they are responsible to pay the $250 copayment. The enrollee received myocardial perfusion imaging on September 3, 2020. Therefore, they are responsible to pay the $250 copayment. The total amount the enrollee owes is $500. The enrollee has been asked to pay the total copayment amount of $500 for a CT scan and myocardial perfusion imaging. A CT scan and myocardial perfusion imaging fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 a CT scan and myocardial perfusion imaging provided on August 21, 2020, and September 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Doxorubicin injection you received on July 15, 2020.
You asked the Plan to waive the coinsurance for the Doxorubicin injection. You say that you haven't been charged coinsurance for other drugs you have received. 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. You have been asked to pay 20% coinsurance for the Doxorubicin injection. The Doxorubicin injection falls within the Medicare Part B drugs benefit category. This coinsurance applies regardless of whether you have been charged for other drugs. 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 Doxorubicin injection you received on July 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 29, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 July 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral exam (D0150) provided September 8, 2020.You asked the Plan to pay forthe oral exam. You say that it has been almost a year since your last visit to a dentists. Since COVID you couldn't go to the dentist for almost 6 months so you will not be able to use your twice a year cleaning benefits.The Plan denied your request. The Plan says this service exceeds the frequency limitation in the benefit 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. Per page 4-74 of the plan contract, this service (D0150) is allowed once every 3 plan years.  The records show that you had received this service on April 18, 2019. 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 forcomprehensive oral exam (D0150) provided September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for protective equipment used during dental services (D1999) provided August 20, 2020 to September 2, 2020.
You asked the Plan to pay for the protective equipment used during dental services. You say that these items should be covered. The Plan denied your request. The Plan says the provider has added the surcharge for the protective equipment used during the procedure. The code billed is not a dental benefit covered under the health plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for protective equipment used during dental services (D1999) provided August 20, 2020 to September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says out-of-network services require prior authorization of which 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 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 physician's services provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure  coded 95999 and the electroencephalogram (EEG) services coded 9599 provided on August 27, 2019.You asked the Plan to pay forthe unlisted neurological or neuromuscular diagnostic procedure  and the electroencephalogram (EEG) services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services withthe appropriate CPT code.We find that CPT codes 95999 and 95955 are not supported in the medical record. Specifically, the operative report did not include documentation of an unlisted neurological or neuromuscular diagnostic procedure. Review of the file shows that train of four neuromuscular junction testing was performed. Code 95999 should not be billed for the train of four neuromuscular junction testing provided. Also, the operative report did not include documentation of  an electroencephalogram (EEG) during nonintracranial surgery (carotid surgery); therefore, code 95955 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure  and the electroencephalogram (EEG) services have not been met.Therefore, we decided that the Plan does not have to pay forthe unlisted neurological or neuromuscular diagnostic procedure  coded 95999 and the electroencephalogram (EEG) services coded 9599 provided on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the bite wing x-rays (D0274), periodontal maintenance (D4910), gingival irrigation (D4921), the denture adjustment (D5410), and the unspecified preventive service (D1999) provided.

You asked the Plan to pay for the dental services. You say that you found this provider on the Plan's Provider Directory. You say that when you called the provider's office, you were advised that they accepted your plan. You say that you cannot afford thi sbill. You say that The Plan denied your request. The Plan says the provider in this case is not the provider that was listed in the directory. The Plan says that the provider in this case is out of network. The Plan says that services that you receive out of network 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, dental services that you receive out of network are not covered.Therefore, we decided that the Plan does not have to pay forthe oral exam (D0120), the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), the bite wing x-rays (D0274), periodontal maintenance (D4910), gingival irrigation (D4921), the denture adjustment (D5410), and the unspecified preventive service (D1999) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for inpatient care provided.

You asked the Plan to waive the copayment for inpatient care. You say that you were at the hospital a day and a half, not three days.The Plan denied your request. The Plan says this processed 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 $220 copayment for each day for days 1-5 of each inpatient admission. You have been asked to pay a $660 copayment for three days of inpatient care. 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 inpatient care provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance angiography, head (70544) provided May 28, 2020
You asked the Plan to waive the copayment for the magnetic resonance angiography. You say that the office did not inform you that you owed a balance. You were told by a plan representative that this policy would not have copayments for certain services. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $300 copayment for Medicare covered diagnostic radiology services. You have been asked to pay $300 copayment for the magnetic resonance angiography. The magnetic resonance angiography 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 magnetic resonance angiography, head (70544) provided May 28, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital observation services provided July 16, 2020 to July 19, 2020.
You asked the Plan to waive the copayment for the observation services. You say that you believe this bill is wrong. You feel that you are not responsible for the entire bill and that it needs to be reviewed as an inpatient bill since you were admitted to the hospital. The Plan denied your request. The Plan says this claim was processed and the correct copayment applied per the Evidence of Coverage.
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 $225 copayment for outpatient hospital observation services. You have been asked to pay $225 copayment for the observation services. The observation services fall within the Outpatient hospital observation 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 hospital observation services provided July 16, 2020 to July 19, 2020.