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

We decided that the Plan does not have to waive the copayment forthe ultrasound you received at an outpatient hospital facility on July 2, 2020.You asked the Plan to waive the copayment forthe ultrasound. You say that this copayment should be waived due to thr Plan's COVID-19 copayment waiver program.The Plan denied your request. The Plan says the copayment waiver program does not apply to these services.  Thewaiver only applies to primary care visits, behavioral health visits, and telehealth services.  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 $95 copayment for diagnostic procedures and tests in an outpatient hospital setting. You have been asked to pay a $95 copayment for the ultrasound. The ultrasound falls within the diagnostic procedures and tests in an outpatient hospital setting benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The copayment waiver program does not apply to this type of service. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe ultrasound you received at an outpatient hospital facility on July 2, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 76830) provided.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says only one unit is supported.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The records provided show that only one unit of CPT 76830 was provided on the date of services in question. The Plan has approved and paid one unit of CPT 76830. The additional billed unit of CPT 76830 is not supported by the records provided. 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 76830) provided.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waivethe $120 copayment charged for emergency room services. You asked the Plan to waivethe emergency room copayment and telehealth cost share. You say that there should be no charge for these services.The Plandenied your request. The Plan says according to the Plan contract agreement there is a $120 copayment for emergency care. The Plan reviewed the claim submitted by the provider which confirmed that you were seen and treated for left leg pain. Based on the above information, the claim processed appropriately, assessing you a $120 emergency room copayment. The Plan states that all covered telehealth services will have no cost-share. 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 $120 copayment for emergency room services. 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 waivethe $120 copayment charged for emergency room services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe medical services provided on July 23, 2020.You asked the Plan to waive the copayment forthe urgent care services. You say that it isn't clear which facilities are urgent care facilities and which are primary care facilities. You say that you weren't aware that you could have gone to a different facility for a lower 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for urgent care services. The enrollee has been asked to pay a $50 copayment for the urgent care 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 copayment forthe medical services on July 23, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvezoledronic acid.You asked the Plan to pre-approvezoledronic acid. You say that you have tried other medications that have not worked.The Plan denied your request. The Plan says that the records received from your PCP do not show that you need zoledronic acid.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 zoledronic acid. Our reviewer says that based on the medical records provided there is documentation that the zoledronic acid is medically reasonable and necessary for the patient. Our physician reviewer found the enrollee will not be due for another infusion of the zoledronic acid until early January 2021. A medical note from provider dated July 22, 2020 indicated the patienthas osteoporosis with a T score of -2.9 in the left femoral neck. She began treatment with zoledronic acid in January 2020 and will be due for another infusion of zoledronic acid in early January 2021.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of zoledronic acid have been met.Therefore, we decided that the Plan has to pre-approvezoledronic acid.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient hospital care provided to the enrollee from 1:05 PM on May 2, 2020 to May 3, 2020.You asked the Plan to pay forthe inpatient hospital care. You say that these services were medically necessary.The Plan denied your request. The Plan says that that the enrollee was stable for transfer.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 hospital care. Our reviewer says that the inpatient hospital care was medically reasonable and necessary for the enrollee in this case.The patient was transferred to a facility in reasonable period of time and medical care provided was appropriate. Using the time of the note as time zero to deny all coverage after that time in thesetting of a timely transfer and an appropriately treated patient does not seem to be practical. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital care.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 hospital care have been met.Therefore, we decided that the Plan has to pay forthe inpatient hospital care provided to the enrollee from 1:05 PM on May 2, 2020 to May 3, 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: Partially Favorable

We decided that the Plan has to make additional payment forthe services at issue. We decided that the Plan does not have to make additional payment forthe services at issue. You asked the Plan to make additional payment forthe services at issue. You say that you do not know why you are paying for dental coverage when the Plan is refusing to make payment along with your other plan.The Plan says that payments made by your primary payer count against what the Plan has to pay as the secondary payer.We decided that the Planhas to make additional payment forthe services at issue.Medicare has rules which decide how much will be paid when Medicare is secondary to a primary plan. Since your dental coverage with your employer's dental plan is primary to your coverage with your Medicare plan, these same rules apply, as described above.In this case, the billed amount (which is the same as the primary payer's allowable charge) from this provider for the filling coded as D2391 was $170, for which $136 was paid. The provider is not disallowed from billing you for the remaining $34. Payments made by the primary dental plan do not satisfy your secondary dental plan's obligation under your contract. As such, the Plan must pay this $34 for the filling, as it is the lowest of the three options above and less than the plan would have paid if there were no primary insurance ($42.75).For the root canal (D3300), the billed amount is $1370 (the primary allowable is $1290) for which the primary plan paid $645, leaving a balance of $725. In this case, the amount payable by the Plan if there were no primary would be $171.25, which is the lowest of the three calculations for secondary payment. These are the payments necessary for the Plan to meets its obligation under its contract with you as a secondary payer. Therefore, we decided that the Plan has to make additional payment forthe services at issue. We also decided that the Plandoes not have to make payment in full for the services at issue.The Plan follows Medicare rules. Medicare rules say that dental services are not covered. The contract with the Plan says that it provides some coverage as listed above. It is noted that enrollees must pay the amount that exceeds the amount payable by the plan for out of network services.In this case, with the payment noted above, the Plan has fulfilledits obligations by paying the maximum amount required under the contract. No additional payment beyond the combined $205.25can be required of the Plan. Therefore, we decided that the Plan does not have to make payment in full for the services at issue.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: Favorable

We decided that the Plan has to provide up to $380 in reimbursement for one of the emergency oral exams, the surgical dental extraction, and the removal of the odontogenic cyst provided from April 28, 2020, to May 14, 2020.
You asked the Plan to provide up to $380 in reimbursement for these dental services. You say that you had these services provided because you were in a lot of pain. You feel that the Plan should reimburse you for the $380 you paid out of pocket. The Plan denied your request. The Plan says that dental care is not covered by Medicare. You do have a dental benefit which will cover up to one intraoral x-ray per year. As such, the Plan approved payment of $16 toward one of the intraoral x-rays received.
The Plan must follow Medicare rules. Medicare rules say that dental care is not covered. However, your Plan offers a supplemental benefit for dental and must abide by its own rules in administering that benefit.
In this case, we find that the Plan has failed to make payment for covered services. There is no rationale provided to justify denial of payment for the surgical extraction and oral surgery procedure (cyst removal) provided. In addition, the plan provides coverage for emergency oral exams, so there is no indication as to why this was denied payment. Payment must be made in full for these codes up to the plan's allowable charge, but not to exceed the total $380 you paid out of pocket. Therefore, we decided that the Plan has to provide up to $380 in reimbursement for one of the emergency oral exams, the surgical dental extraction, and the removal of the odontogenic cyst provided from April 28, 2020, to May 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided by an out-of-network (OON) provider.

You asked the Plan to pay for the hearing aids. You say that you should be reimbursed for the hearing aids.The Plan denied your request. The Plan says the rules for hearing aid coverage have not been met.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only they are provided by the Plan's hearing aid vendor.

We looked at the file and the Plan's rules. The file indicates that you received the hearing aids from an OON provider and not the Plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay fo rthe hearing aids provided by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not support medical necessity after several attempts to get the documentation required.
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 March 20, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post-stabilization inpatient services provided from January 15, 2020 to January 16, 2020. You asked the Plan to pay for the post-stabilization inpatient services. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee was stabilized in the ED and able to be transferred to an in network facility. 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 post-stabilization inpatient services. Our reviewer says that the service at the out of network facility was not medically necessary. Our physician reviewer found the enrollee was approved for ED care. The enrollee was not approved for post-stabilization care. The enrollee was admitted and it appears that the enrollee was stable for transfer to another facility. Therefore, the denial is upheld. 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 post-stabilization inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the post-stabilization inpatient services provided from January 15, 2020 to January 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plandoes not haveto pay foremergency room services provided to the enrollee on June 28, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysno provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. You are not eligible to bill Medicare. The plan did not pre-approve the services. We found no exception that would require the plan to pay for these items/services.Therefore, we decided that the Plandoes not haveto pay foremergency room services provided to the enrollee on June 28, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 25, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe durable medical equipment (99214, 80307, and L1833). You say that the claim should be paid.The Plan denied your request. The Plan says the services were not emergent, out of area, or preapproved.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 June 25, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a chemotherapeutic regimen received on January 27 to March 9, 2020.
You asked the Plan to waive the coinsurance for a chemotherapeutic regimen. You say that the Plan should review these charges and adjust accordingly. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered chemo drugs. You have been asked to pay less than or equal to 20% coinsurance for a chemotherapeutic regimen. A chemotherapeutic regimen falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a chemotherapeutic regimen received on January 27 to March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits you had with an
otolaryngologist on June 12, 2020, and July 16, 2020.

You asked the Plan to waive the copayments for the specialist visits. You say that you were told that all fees
were being waived due to COVID-19. The Plan denied your request. The Plan says you were charged these
copayments correctly. The Plan says that there is no evidence that you were provided incorrect copayment
information from the Plan. The Plan says that it is only waiving copayments for primary care, telehealth visits,
and outpatient behavioral health services.

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 specialist visits.

You have been asked to pay a $35 copayment for the specialist visits. The Plan's current copayment waiver
program only applies to primary care, telehealth visits, and outpatient behavioral health services. It does not
apply to specialist visits, such as the visits in dispute in this case. 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 office visits you had with an otolaryngologist on June 12, 2020, and July 16, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the services you received on May 23, 2020.

You asked the Plan to pay for the services. You say that you were told this provider is in-network. The Plan
denied your request. The Plan says that this provider is not enrollee in Medicare.

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.

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 says that this provider is not enrollee in the Medicare program.
However, an NPPES NPI Registry search shows that this provider's NPI is active in the CMS system. The Plan
has not provided documentation supporting its denial. Without supporting documentation the Plan's denial
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services you received on May
23, 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.