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

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 25, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that there is no other place to go to get a blood test. You say that you need a way to make the blood test more affordable. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment each Medicare-covered laboratory test in an outpatient hospital facility. The enrollee has been asked to pay a $30 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the laboratory services were provided by the hospital. 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 laboratory services provided on February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation.
You asked the Plan to pre-approve the second opinion consultation. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a second opinion consultation to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on December 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must first be
submitted to the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified
the plan as the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan
does not have to pay for the services you received on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 25, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you went for a blood pressure check not an office visit. You say that you shouldn't have to pay the copayment. 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 $10 for each covered visit or consultation in an outpatient location with your PCP or other primary care provider. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated for hypertension and hypothyroidism during the office 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 office visit provided on February 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dental services. You say that this is the only provider you are comfortable with. The Plan denied your request. The Plan says that there are in network providers who have the same training and expertise as the requested out of network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 24, 2019 through September 26, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you had a bad experience. You say that you won't be paying this bill. 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 $300 each time you are admitted to an acute care hospital. You have been asked to pay a $300 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that you admitted as an inpatient for three days. 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 inpatient stay provided from September 24, 2019 through September 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on December 11, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that no one told you that you would have a coinsurance. You say you cannot afford to pay this bill. 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 Medicare-covered Part B prescription drugs. You have been asked to pay $186.56 which is 20% of the allowed amount for the Part B injection. The allowed amount is $932.80. ($932.80 x 20% = $186.56). The Part B injection 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 the Part B injection provided on December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from February 4, 2020 to February 7, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment because it is a financial hardship. 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 $300 copayment for each time you are admitted to an acute care hospital. You have been asked to pay a $300 copayment for the inpatient hospital stay. The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from February 4, 2020 to February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the medical eye exam provided on March 9, 2020.
You asked the Plan to reduce the copayment for the medical eye exam. You say that you were told the copayment for a routine eye exam would have a $15 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 $40 copayment for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The medical record shows a diagnosis of age-related cataracts which makes the eye exam medical in nature.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the medical eye exam provided on March 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to ENROLLEE on July 12, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered to ENROLLEE on July 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hearing aids and batteries provided on January 3, 2020.You asked the Plan to pay forthe hearing aids and batteries. You say that you were told this provider was in network.The Plan denied your request. The Plan says that there is no coverage if hearing aids or related services are received from a provider not part of the plan's hearing aid vendor's network.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 when provided by the provider. We looked at the file and the Plan's rules. The file indicates you did not receive these services from the provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids and batteries have not been met.Therefore, we decided thatthe Plan does not have to pay forthe hearing aids and batteries provided on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 3, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that labs fees are supposed to be waived if administered as part of a physical exam. You say that you were advised it would be waived. 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 $5 per day for Medicare-covered laboratory services. You have been asked to pay a $5 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on February 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on February 3, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you believe the charge is a lot of money. You say this will be a financial hardship. 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 $100 copayment for per day for Medicare-covered diagnostic radiology services (ultrasound). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $100 copayment for the ultrasound.
You have been asked to pay a $67.87 copayment for the ultrasound. The ultrasound 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 ultrasound provided on February 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on February 28, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you should have been charged $35. 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 $35 copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy services. A separate copayment applies to the initial evaluation and any re-evaluations.
You have been asked to pay a total of $70 for physical therapy services.
Date of Service
Service
Standard Copayment
Member Liability
February 28, 2020
Physical Therapy Re-Evaluation
$35
$35
February 28, 2020
Physical Therapy
$35
$35
TOTAL:
$70
Physical therapy falls 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 copayment for physical therapy provided on February 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the laboratory work, the specialist office visit, and the emergency room visit provided from November 6, 2019 to March 13, 2020.
You asked the Plan to waive the cost share for the laboratory work; the specialist office visit, and the emergency room visit. You say that the bill has already been paid in full. 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 $15 copayment for Medicare-covered lab services, a $30 copayment for Medicare-covered specialist visits, and a $90 copayment for Medicare-covered emergency room visits. You have been asked to pay a total of $127.79 for the laboratory work, the specialist office visit, and the emergency room visit. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The emergency room visit falls within the "Emergency care" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
November 6, 2019
Laboratory work
$11.97
$15.00
$11.97
February 18, 2020
Specialist office visit
$25.82
$30.00
$25.82
March 13, 2020
Emergency room visit
$414.90
$90.00
$90.00
Total
$127.79
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 cost share for the laboratory work, the specialist office visit, and the emergency room visit provided from November 6, 2019 to March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on April 27, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that the enrollee should not be liable for the cost share due to limited access to providers in his area. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for each Medicare-covered laboratory test in an in-network outpatient hospital facility. The enrollee has been asked to pay a $30 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work was provided at an outpatient hospital.
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 the laboratory work provided on April 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve outpatient mental health. You say that you would like a provider who can provide care for Parkinson's related depression. The Plan denied your request. The Plan says there are in-network providers available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on March 30, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that there is no other place to go to get a blood test. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment each Medicare-covered laboratory test in an outpatient hospital facility. The enrollee has been asked to pay a $30 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the laboratory services were provided by the hospital. 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 laboratory services provided on March 30, 2020.