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

We decided that the Plan does not have to pay forthe immediate maxillary denture and 7 additional extractions provided on August 13, 2019.You asked the Plan to pay forthe immediate maxillary denture and 7 additional extractions. You say that you were told that your insurance would cover a large portion of this procedure.The Plan denied your request. The Plan says the benefits for these services has been satisfied and the frequency limitation has been exceeded.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, extractions are limited to two procedures per calendar year. The record shows that you received two extractions on August 13, 2019 that the Plan paid for 50% of the cost share for each of the two and your extractions benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe immediate maxillary denture and 7 additional extractions provided on August 13, 2019.Your complaint about being given an incorrect timeframe for receiving your dentures and the provider not shaving your bone downis 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee byan in-network providerfrom May 4, 2019 through May 7, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were advised by physicians for a procedure done the day before that if there were any complications to seek help at the emergency department.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).Review of the file shows that the enrollee was admitted to an in-network provider on May 4, 2019 and discharged on May 7, 2019. The enrollee was asked to pay a $330 copayment per day from May 4, 2019 through May 6, 2019, days 1-3 of their inpatient hospital care. The enrollee was discharged on May 7, 2019 and there was no copayment charge for the day of discharge. Per the enrollee's contract there is a $330 copayment per day required for days 1-20. This means that the enrolleehas been asked to pay the correct amount based on the contract with the Plan. This cost sharingis a contractual obligation the enrolleeagreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided to the enrollee by an in-network provider from May 4, 2019through May 7, 2019.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to waive the copayment forthe psychiatric diagnostic evaluation on August 22, 2019.You asked the Plan to waive the copayment forthe psychiatric diagnostic evaluation. You say that you were evaluated in a clinic and you should not have to pay the $55 copayment. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.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 did not submit medical records to support that this service was provided on a partial hospitalization basis and not on an outpatient mental healthcare basis. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment forthe psychiatric diagnostic evaluation provided on August 22, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to "the beneficiary" by an out-of-network provider on May 28, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided to "the beneficiary" by an out-of-network provider on May 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone replacement graft, osseous surgery, and biologic materials to aid in soft and osseous tissue regeneration provided on September 19, 2019.You asked the Plan to pay forthe bone replacement graft, osseous surgery, and biologic materials. You say that this service should have been considered medical because you had a severe infection that needed to be taken care of right away. You also say that you called the Plan about these services and were told that you had a $300 copay and $40 for the office visit.The Plan denied your request. The Plan says at the time of these services, you only had $14.00 remaining of your annual benefit allowance. The Plan also says that this this service is not covered medically.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 Plan offers a $300 annual dental benefit maximum. The contract says that after your annual deductible benefit maximum has been met, you are responsiblefor the full charges of any additional dental services. The record shows that you met the annual deductible benefit on September 19, 2019 and your annual deductible benefit had been exhausted.Therefore, we decided that the Plan does not have to pay forthe bone replacement graft, osseous surgery, and biologic materials to aid in soft and osseous tissue regeneration provided on September 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health physical therapy services provided on August 12, 2019 by out-of-network provider.You asked the Plan to pay forthe services provided. You say that the services were provided to restore functional abilities in a safe manner.The Plan denied your request. The Plan says prior authorization is required for these services.The Plan must follow Medicare rules. Medicare rules say that plansmay choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 forthe home health physical therapy services provided on August 12, 2019 by out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services providedon August 27, 2019.You asked the Plan to pay for the nurse practitioner services.The Plan denied your request. The Plan says that thePlan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 Plandid not pre-approve the servicesat 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 nurse practitioner services provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 30, 2019 by out of network provider.You asked the Plan to pay forthe out-of-network services. You say that the treatment was medically necessary as to not compromise the enrollee's health.The Plandenied your request. The Plan says services rendered by non-participating 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay fortheoffice visit providedon May 30, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hernia repair provided on August 2, 2019.
You asked the Plan to waive the copayment for the hernia repair. You say that you were not aware of a cost change at the time of surgery. You say that you do not feel responsible for the $150. 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 $150 for each visit to an outpatient hospital facility. You have been asked to pay a $150 for the hernia repair. The hernia repair falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the surgery was performed at the hospital. 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 hernia repair provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 23, 2019 by the out of
network provider.
You asked the Plan to pay for office visit. You say that your physician was asked to consult this enrollee. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider
is out-of-network with the Plan and the claim submitted does not reflect that the enrollee was in observation at
the time of service.
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 August 23, 2019
by the out of network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency department (ED) visit (99284) and hospital observation services (G0378) provided from June 13, 2019 to June 14, 2019 by "the hospital". You asked the Plan to waive the copayment forthe ED visit and hospital observation services. You say that youwere not advised how much the copayment would be.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all costsharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $600 copayment for each outpatient hospital and observation service. You have been asked to pay $600 for the ED visit andhospital observation services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran emergency department (ED) visit (99284) and hospital observation services (G0378) provided from June 13, 2019 to June 14, 2019 by "the hospital".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leisure form, breast prosthesis, and bras to be provided by the out of network provider.
You asked the Plan to pre-approve the leisure form, breast prosthesis, and bras. You say that you want to have more of a selection and personal experience than the in network suppliers provide. The Plan denied your request. The Plan says there are par providers available for this item.
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 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. 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 a leisure form, breast prosthesis, and bras to be provided by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on September 3, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that you were informed your copayment would be$125. You say that the Plan should pay the remaining amount.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 $150 copayment for advanced imaging services at an in-network freestanding radiological facility.You have been asked to pay a $150 copayment for theCT scan. The CT scan 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 forthe CT scan provided on September 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.You asked the Plan to pre-approve SNF services. You say that you cannot get out of bed or go to the toilet by yourself.The Plan denied your request. The Plan says you do not require daily skilled care on an inpatient basis.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and your lungs are clear. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a modified independent to standby assist level with functional mobility. You require varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care services provided to the enrollee on April 30, 2019, by an out-of-network provider.
You asked the Plan to pay for vision care services. You say that you were aware the enrollee had the Plan coverage and that they are not in-network. The Plan denied your request. The Plan says the enrollee does not have out-of-network benefits.
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 enrollee was seen for a glaucoma evaluation with no associated symptoms. The enrollee had glaucoma for 10 years. 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 vision care services provided to the enrollee on April 30, 2019, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for nerve conduction studies and office visits provided by the doctor from September 19, 2019 to September 26, 2019.You asked the Plan to waive the copayment for diagnostic tests and office visits. You say that you were not aware of any cost-sharing beyond the office visit copayments, and were not informed that you would be charged this amount.The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.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 $400 copayment for diagnostic tests and $40 copayment for each specialist office visit. For date of service September 19, 2019 you have been asked to pay $400 copayment for diagnostic tests and $40 copayment for an office visit. For date of service September 26,2019 you have been asked to pay the allowed amount of $374.27 for diagnostic tests, because this is less than the $400 copayment for diagnostic tests, and $40 copayment for an office visit. You total cost-sharing obligation is therefore $854.27.You have been asked to pay $400 copayment or less for diagnostic tests and $40 copayment for each office visit. Diagnostic tests and office visits fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and "Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 nerve conduction studies and office visits provided by the doctor from September 19, 2019 to September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from March 1, 2019 to March 29, 2019.You asked the Plan to pay forhome health services. The Plan denied your request. The Plan says the claim was billed with an invalid type of bill.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim submitted was not billed with a valid type of bill code. Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from March 1, 2019 to March 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided by an in-network
provider from January 8, 2019 through April 8, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you spoke to numerous people in an
attempt to resolve the issue and that per your provider you are supposed to be 100% covered for the DME. The
Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received DME provided by an in-network provider from January 8, 2019
through April 8, 2019. You are asked to pay 20% coinsurance for the DME. 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 DME provided by an in-network provider from January 8, 2019 through April
8, 2019.