Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diagnostic tests and Part B drugs provided on June 13, 2019.You asked the Plan to waive the coinsurance for the diagnostic tests and Part B drugs. You say that you were informed the doctor was in-network. You say that you paid your copayment and wonder why you owe more money.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered non-radiological and radiological diagnostic services and 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a total of $126.04 for the diagnostic tests and Part B drugs. The diagnostic tests fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Part B drugs fall 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 diagnostic tests and Part B drugs provided on June 13, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the resin based composites and extractions provided on June 19, 2019. We decided that the Plan does not have to hold you harmless for the periodic oral evaluation provided on June 24, 2019.
You asked the Plan to hold you harmless for the resin based composites, extractions and periodic oral evaluation. You say that a portion of the work has not been completed. You say that your account should be credited. The Plan says that these are not covered.
We decided that the Plan has to hold you harmless for the resin based composites and extractions provided on June 19, 2019.
The resin based composites and extractions are listed as covered benefits and were provided by an in-network provider. Therefore, we decided that the Plan has to hold you harmless for the resin based composites and extractions provided on June 19, 2019.
We also decided that the Plan does not have to hold you harmless for the periodic oral evaluation.
The Plan contract has a maximum benefit of two oral evaluations per calendar year. The Plan has paid for an oral evaluation on March 18, 2019 and June 3, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to hold you harmless for the periodic oral evaluation provided on June 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit for ophthalmology services provided by your doctor on May 15, 2019.
You asked the Plan to waive the copayment for the specialist office visit for ophthalmology services. The Plan denied your request. The Plan says the correct copayment has been applied to the specialist office visit for vision care.
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 $45 copayment for vision care. or 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 $45 copayment for the specialist office visit for ophthalmology services. The specialist office visit for ophthalmology services falls within the vision care benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation that you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit for ophthalmology services provided by your doctor on May 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received on August 27, 2019.
You asked the Plan to waive the copayment. You say that you shouldn't have to pay a second copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $10 copayment for Medicare-covered lab tests. Review of the file shows that you were provided lab services on August 27, 2019. You have been asked to pay a $10 copayment for the lab services. The lab services fall within the outpatient diagnostic tests 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 lab services you received on August 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on July 12, 2019 by the out of network provider.
You asked the Plan to pay for the laboratory testing. You say that Guardant is the only service provider for the Guardant360 testing. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says that the enrollee self-directed for the services. The Plan also says that the services can be provided in network.
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 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 Guardant360 testing provided on July 12, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on July 26, 2019.
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 physician order is insufficient in detail.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case. The physician order lacks detail on the specifications of back brace prescribed. Without the specifications of the back brace listed, the service cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on July 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 28, 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 procedure code 43753 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 43753 is gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed.We find that CPT code 43753 is not supported in the medical record. Specifically, there is no documentation in the operative report of gastric intubation and aspiration being performed. 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 surgical services rendered on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 22, 2019 by out of network provider.You asked the Plan to pay for nerve injection services. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 July 22, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic biometry provided on April 24, 2019.You asked the Plan to waive the copayment for ophthalmic biometry. You say that you disagree with the charges.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 $20 copayment for outpatient diagnostic tests.The medical records show that you received ophthalmic biometry on April 24, 2019. Ophthalmic biometry is considered an outpatient diagnostic test. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for ophthalmic biometry. Ophthalmic biometry 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 ophthalmic biometry provided on April 24, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waivethe copayments charged for mental health care provided from May 22, 2019 to June 24, 2019 by "the out of network provider" (out of network) and "in network provider" (in network).You asked the Plan to waivethis cost share. You say that you do not believe you owe these payments. You stated that you do not recall receiving the treatment for environment manipulation.The Plan denied your request. The Plan says this cost share was applied based on the services provided and the Plan contract agreement.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 $1528 copayment for in network inpatient mental health care and 30% coinsurance for out of network inpatient mental health care. 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 copayments charged for mental health care provided from May 22, 2019 to June 24, 2019 by "the out of network provider" (out of network) and "the in network provider" (in network).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the implant (D6010), the bone graft with implant placement (D6104), the guided tissue membrane (D4266), the initial 15 minutes of anesthesia (D9239), each additional 15 minutes ofanesthesia (D9243 x 2) provided on August 27, 2019.You asked the Plan to pay for the implant, bone graft, guided tissue membrane, and anesthesia. You say that the services should be covered.The Plan denied your request. The Plan says the maximum benefit allowance of $2,250 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, the maximum benefit allowance of $2,250 has been exceeded. The record shows that the maximum benefit allowance was reached during the processing of the claim.Therefore, we decided that the Plan does not have to pay for the implant (D6010), the bone graft with implant placement (D6104), the guided tissue membrane (D4266), the initial 15 minutes of anesthesia (D9239), each additional 15 minutes of anesthesia (D9243 x 2) provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the services provided on July 8, 2019.You asked the Plan to waive the copayments for the services provided on July 8, 2019. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says the correct cost share has applied per your contract with the plan.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 Outpatient diagnostic tests, a $35 copayment for laboratory services, a $5 copayment for physician services, and a $0 copayment for your annual wellness visit. We looked at the file, the Plan contract and Medicare rules. The file shows you received an x-ray, physician services, laboratory services, and an annual wellness visit on July 8, 2019. You have been asked to pay a $25.87 copayment for the x-ray, which is less than the contracted $35 copayment amount. You have also been asked to pay a $21.67 copayment for the laboratory services, which is less than the contracted $35 copayment amount. The x-ray and laboratory services fall within the Outpatient diagnostic tests benefit category. You have also been asked to pay a $5 copayment for the physician services on July 8, 2019. The physician services fall 
within the Physician/Practitioner benefit coverage.You have also been asked to pay a $0 copayment for the annual wellness visit provided on July 8, 2019. The annual wellness visit falls within the Annual Wellness Visit benefit category. This means that you have been asked to pay the correct amounts 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 services provided on July 8, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning (D1110) provided on September 5, 2019.
You asked the Plan to pay for the cleaning (D1110). You say that two cleanings are payable twice every calendar year. The Plan denied your request. The Plan says the service is covered, but the benefit is exhausted.
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, there is a benefit limit for the cleaning. The plan clearly states that only one cleaning is covered every year. The records show the Plan paid for one cleaning (D1110) on January 10, 2019, which exhausted the benefit. The record also shows you are only eligible for the embedded dental benefit, and not the enhanced dental package. Therefore, we decided that the Plan does not have to pay for the cleaning (D1110) provided on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bite wing x-rays and cleaning provided on August 21, 2019.You asked the Plan to pay for the periodic oral evaluation, bite wing x-rays and cleaning. You say that you were informed the provider took your insurance.The Plan denied your request. The Plan says services need to be provided in-network to be eligible for payment.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, out-of-network dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays and cleaning provided on August 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe injections provided from July 30, 2019 to August 13, 2019.You asked the Plan towaive the coinsurance forthe injections. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received Part B injections on the dates of service at issue in this appeal. The plan states the correct coinsurance has applied to each injection per your contract with the plan.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 20% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan contract and Medicare rules. The file shows that you received injections on July 30, 2019, August 6, 2019, and August 13, 2019. You have been asked to pay a 20% coinsurance for each injection for each date of service, totaling $585.06 for all three dates of service. The injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amounts 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 forthe injections provided from July 30, 2019 to August 13, 2019.Your concern regarding the increase in cost of your injectionsis a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of concerns
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you received a bill for services that you thought had been paid already.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 May 15, 2019. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic testing supplies provided to the enrollee from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for the diabetic testing supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says an acceptable delivery ticket was not submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Review of the file shows that the submitted delivery ticket did not include the carrier's tracking number. The proof of delivery did not include an order number or details to match to the delivery ticket submitted. Therefore, we decided that the Plan does not have to pay for the diabetic testing supplies provided to the enrollee from August 9, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 8, 2019 to April 29, 2019.You asked the Plan to pay for this service. You say that these services should be covered.The Plan denied your request. The Plan says only those services related to manual manipulation of the spine are covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for chiropractic services provided from January 8, 2019 to April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forbiological materials, the implant removaland bone replacement graftprovided on August 1, 2019.You asked the Plan to pay forbiological materials, the implant removaland bone replacement graft. You say that the crown broke off and damaged the implant post in your gum. You say that it was necessary to be removed.The Plan denied your request. The Plan says these are not covered benefits.Medicare generally does not cover dental services. However, the Planoffers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forbiological materials, the implant removal and bone replacement graft provided on August 1, 2019.