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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on August 20, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that it was not your choice to go to the emergency room. You say your primary care physician forced you to go to the emergency room. 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 $90 copayment per visit for Medicare-covered emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you had an emergency room 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 emergency room visit provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 20, 2019 to November 8, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries
(A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery
Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to
corroborate the Delivery Ticket.
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 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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips,
lancets, control solution, and batteries provided from August 20, 2019 to November
8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 19, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the additional 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 $225 copayment for advanced imaging services. You have been asked to pay a $225 copayment for a CT scan. A 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 for a CT scan provided on August 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management service (99239) provided on October 11, 2018.
You asked the Plan to pay for the hospital discharge day management service. You say that the medical records provided support the necessity of the services in dispute The Plan denied your request. The Plan says the records do not support the service billed.
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 99239 is hospital discharge day management service. We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management service have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management service (99239) provided on October 11, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 26, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that 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 $250 copayment for Ambulance services. You have been asked to pay $250 copayment for the ambulance transport. The ambulance transport falls within the Ambulance 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 the ambulance transport provided on June 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 19,
2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were informed the CT scan was
covered. You say that you thought it would be covered in full. 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 $100
copayment for each in-network Medicare-covered MRI, CT or PET scan.
You have been asked to pay a $100 copayment for the CT 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 for the CT scan provided on September 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for knee surgery provided on September 6, 2019.
You asked the Plan to waive the copayment for knee surgery. You say that you were informed everything would be paid in full. 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 for surgical services at an in-network ambulatory surgical center. You have been asked to pay a $275 copayment for knee surgery. Knee 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 waive the copayment for knee surgery provided on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist/hand orthosis (L3916) provided on April 17, 2019.
You asked the Plan to pay for the orthosis. You say that the medical records provided support the necessity of
the services in dispute. The Plan denied your request. The Plan says the records do not support the service
billed.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee had L3960 which was provided March 1, 2019. at the time the
orthosis was received. L3960 which was provided March 1, 2019. serves the same purpose as the
orthosis. Therefore, we decided that the Plan does not have to pay for the wrist/hand orthosis (L3916) provided
on April 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of
Delivery did not include details to corroborate the Delivery Ticket.
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 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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose
monitor, test strips, lancets, control solution, and lancet device provided from
August 9, 2019 to October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions of erupted tooth or exposed root of tooth #'s 9, 10, and 11, extraction of erupted tooth requiring removal of bone and/or sectioning of tooth, and local anesthesia in conjunction with operative or surgical procedures provided on August 19, 2019.
You asked the Plan to pay for the extractions and local anesthesia. You say that you fell down, pieces of your teeth broke, and you cut your lip. You also say that you had insurance with dental benefits. The Plan denied your request. The Plan says you had exceeded the limits set in the subscriber agreement. The Plan also says that the Plan cannot issue payment for dental services above the maximum allowable of $1,000.
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 $1,000 annual dental benefit maximum and after your annual deductible benefit maximum has been met you are responsible for the full charges of any additional dental services. The record shows that you met the annual deductible benefit on March 21, 2019 and your annual deductible benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the extractions of erupted tooth or exposed root of tooth #'s 9, 10, and 11, extraction of erupted tooth requiring removal of bone and/or sectioning of tooth, and local anesthesia in conjunction with operative or surgical procedures provided on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam, CT, surgery implant, bone graft, deep sedation, drug injection, and office visits for observation provided from January 7, 2019 to May 13, 2019.
You asked the Plan to pay for the dental services. You say that you called member services prior to having the implants and were told that you did not need a referral and could see a provider of your choice. You also say that these teeth were not implanted for appearance, but for medical necessity. The Plan denied your request. The Plan says you received non-covered services without prior authorization.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral exam, CT, surgery implant, bone graft, deep sedation, drug injection, and office visits for observation provided from January 7, 2019 to May 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services (G0156).
You asked the Plan to pre-approve home health aide services. You say that you are entitled to home health services and want a home health aide for house cleaning and dressing. The Plan denied your request. The Plan says the requested services are not skilled services and are therefore not covered by Medicare.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We looked at the file and Medicare rules. The home health aide services you have requested are for house cleaning and dressing. These services are not skilled nursing or therapy services that are covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services (G0156).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on September 24, 2019.
You asked the Plan to pay for the comprehensive oral evaluation and intraoral x-rays. You say that the Plan provided you with this dentist, being the only dentist available within a lesser distance. You also say that there were no providers who were in-network in the area you live. The Plan denied your request. The Plan says this dentist is an out-of-network provider. The Plan also says that there is no call on file in which this provider was discussed, and you were referred elsewhere.
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 requested items or services are not covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the legal blood draw rendered to you on July 26, 2019.
You asked the Plan to pay for these services. You say that the services were for a cat bite. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay the benefits to any other person or organization under an assignment or reassignment, power of attorney, or under any other arrangement in which the other person or organization receives the payment directly. We looked at the file and Medicare rules. The file shows that the services were a court-ordered blood draw for alcohol/drug level testing. There is no documentation to show that the services were related to a cat bite. Therefore, we decided that the Plan does not have to pay for the legal blood draw rendered to you on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on May 3, 2019 by the out of network provider.
You asked the Plan to pay for an MRI and injection. You say that you would like the Plan to reconsider payment for this claim. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are multiple in-network providers within 30 miles of the member's residence that could have rendered 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 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 outpatient services provided on May 3, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 22, 2019 to October 10, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 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. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 22, 2019 to October 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 7, 2019.
You asked the Plan to pay for the ultrasound (93925). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there was no authorization for these services and there are network-providers available.
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 June 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 29, 2018.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was submitted more than one year from the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the laboratory services was not filed until April 27, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on March 7, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were brought into the office to get negative test results. You say you should not be responsible for the copayment because this information could have been given over the phone. 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 in-network specialist office visit for Medicare-covered services. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows 20 minutes of face-to-face time was used to discuss the test results and answer questions.
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 specialist office visit provided on March 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on August 2, 2019.
You asked the Plan to waive the copayment for an MRI. 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 $25 copayment for diagnostic radiology. You have been asked to pay a $25 copayment for an MRI. An 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 an MRI provided on August 2, 2019.