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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from October 29, 2020, to November 5, 2020.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 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 continued stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 continued stay have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from October 29, 2020, to November 5, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on October 1, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were not supposed to go to the hospital but went due to the recommendation of the health provider. You say that you can't make the payment. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show you were treated in the ER. 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 ER visit provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nail debridement provided on November 4, 2020.
You asked the Plan to waive the copayment for nail debridement. You say that you only paid $30 or $45 before this bill. You say that you won't be able to go to this doctor with bills like this. 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 $200 copayment for each outpatient hospital and observation service. You have been asked to pay $192.75, which is less than the standard $200 copayment for nail debridement. The nail debridement falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for nail debridement provided on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on August 27, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you feel that the X-ray should be included in the follow-up visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for X-rays. You have been asked to pay a $15 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (95999) provided on June 25, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. We looked at the file and Medicare rules. The requested train of four testing is a bundled service. Payment for this service is included in the payment for the primary procedure. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (95999) provided on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ultraviolet light therapy system (E0691), ankle foot orthosis (L1971) and shoulder elbow wrist hand orthosis (L3960) provided on August 10, 2020.
You asked the Plan to pay for the billed equipment. You say that you would like reconsideration because these supplies are medically necessary. The Plan denied your request. The Plan says there is no evidence that the physician discussed the need for the billed supplies.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 billed equipment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file indicates that the order for the requested supplies and equipment was signed in August 2020. The office visit note is from September 2020. 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 billed equipment have not been met. Therefore, we decided that the Plan does not have to pay for ultraviolet light therapy system (E0691), ankle foot orthosis (L1971) and shoulder elbow wrist hand orthosis (L3960) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 28, 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 October 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for a hernia repair surgery provided by St. Catherine of Siena Medical Center on September 14, 2020.
You asked the Plan to reduce the coinsurance for the repair surgery. You say that you were told you would only have to pay around $350 for the surgery. The Plan denied your request. The Plan says you have been asked to pay 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 25% coinsurance for each covered surgery or observation room service in an outpatient hospital. You have been asked to pay $941.74 which is 25% coinsurance of the allowed amount for the repair surgery. The allowed amount is $3,766.97. ($3,766.97 x 25% = $941.74). The repair surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for the hernia repair surgery provided on September 14, 2020.
Your complaint about the Plan's customer service's negligence is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Alginate dressing rendered on November 24, 2020.
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 procedure code A6196 is not separately payable.
The Plan must follow Medicare rules. The rules say that supplies are included in payment of the global surgical package. We looked at the file and Medicare rules. Payment for procedure code A6196 (Alginate dressing) is included in the global surgical package for the surgical procedure billed with cod 11042 (debridement of subcutaneous tissue). Separate payment is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Alginate dressing rendered on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services provided on September 24, 2020.
You asked the Plan to pay for the surgical pathology. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 surgical pathology services provided on September 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) and cone beam image capture (D0367) provided on November 10, 2020.
You asked the Plan to pay for the dental services. You say that these services were medically necessary, and you need reimbursement. The Plan denied your request. The Plan says these services were received from providers who have opted-out of Medicare, and therefore no payment can be made.
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 denied these services on the basis that they were received from dental providers who have chosen to opt-out of Medicare participation. Normally, providers who have opted-out of Medicare are unable to submit claims and receive payments from Medicare plans for medical services. However, the Centers for Medicare and Medicaid Services (CMS) has stated that opt-out rules do not prevent a provider from being paid for non-Medicare covered (supplemental) benefits, unless the Plan specifically states this limitation in the contract. The Plan did not make a statement including or excluding the use of opt-out providers for non-Medicare covered dental services in the 2020 contract.
However, while the Plan offers a dental benefit in excess of Medicare coverage, the requested problem-focused evaluation and cone beam image capture are not listed as covered services under this benefit. This means that the Plan does not have to cover these services regardless of who provides them. Therefore, we decided that the Plan does not have to pay for the problem-focused oral evaluation (D0140) and cone beam image capture (D0367) provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on August 10, 2020.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 6,2020, through October 19, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that the hospital does not know the amount billed or the amount for the claim. 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 $275 copayment per day, days 1 to 7, at an in-network inpatient hospital. You have been asked to pay a $1,925 copayment for the inpatient stay. ($275/day x 7 days = $1,925). The inpatient 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 stay provided from October 6,2020, through October 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the SPECT test provided on December 11, 2020.
You asked the Plan to reduce the copayment for the SPECT test. You say that you were told you would have a $35 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $200 copayment for CT, MRI, MRA, and SPECT scans. You have been asked to pay a $200 copayment for the SPECT test. The SPECT test 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 reduce the copayment for the SPECT test provided on December 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 30, 2020.
You asked the Plan to pay for the ambulance services. You say that you did not call for this service. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 30, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services on October 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 18, 2020.
You asked the Plan to pay for the ambulance services. You say that this service saved your life and should be covered. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 18, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 18, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 21, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that the after-call urology office advised you to go to the emergency room for treatment. You say that you are appealing the copayment due to the short time between discharge and readmission. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for Medicare-covered emergency room visits. You have been asked to pay a $75 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show this was a separate ER 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 ER visit provided on November 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 7, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 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 October 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 9, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you did not know you would be responsible for this amount of money. You say that you want the charge reconsidered. 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 $250 copayment for covered diagnostic radiology services in the outpatient department of a network hospital or facility. You have been asked to pay a $250 copayment for the MRI. The MRI 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 MRI provided on January 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cochlear implantation surgery and the physical therapy evaluation provided from October 6, 2020, to October 7, 2020.
You asked the Plan to waive the copayments for the cochlear implantation surgery and the physical therapy evaluation. You say that you were under the impression that all charges for the surgery would be covered by insurance. The Plan denied your request. The Plan says you have been asked to pay 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 $250 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $35 copayment for each in-network Medicare-covered physical therapy and speech-language therapy visit. You have been asked to pay a $250 copayment for the cochlear implantation surgery and a $35 copayment for the physical therapy evaluation. The cochlear implantation surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The physical therapy evaluation 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 copayments for the cochlear implantation surgery and the physical therapy evaluation provided from October 6, 2020, to October 7, 2020.