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

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on July 21, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance has been applied.
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/in-network/physician office. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $16.25. The total amount you are being asked to pay is $3.25 ($16.25 x 20% = $3.25). An injection falls within the Medicare Part B prescription drugs/in-network/physician office 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 an injection provided by a participating provider on July 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery provided on November 23, 2020.
You asked the Plan to pay for the outpatient surgery. The Plan denied your request. The Plan says the member must receive care from a network provider. In most cases, care received from an out-of-network provider will not be covered.
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 outpatient surgery. 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 outpatient surgery provided on November 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on October 22, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you were told that the results would be available but they were not. The Plan denied your request. The Plan says the claims were provided correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for each basic imaging service. The enrollee has been asked to pay a $40 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac evaluation to be provided by an out of network provider.

You asked the Plan to pre-approve a cardiac evaluation at an out of network clinic. You say that the enrollee requires a specialist to manage care. The Plan denied your request. The Plan says an out of network service exception is not necessary.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a cardiac evaluation to be provided by an out of network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Evenity (J3111).
You asked the Plan to pre-approve Evenity. You say that Evenity is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee has not tried one of the preferred drugs, Prolia or Reclast (Zoledronic acid).
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract does not clearly indicate whether the Plan has implemented step therapy criteria applicable to Evenity. We looked at your contract with the Plan. We did not see where the contract says that step therapy rules have been implemented for use of Evenity. The Plan did not provide any other rationale to support a denial for the requested Evenity. Based on this information, we decided that Medicare rules for coverage of Evenity have been met. Therefore, we decided that the Plan has to pre-approve Evenity (J3111).
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an ultrasound provided by a participating provider on January 14, 2020.
You asked the Plan to waive the deductible for an ultrasound. You say that you did not know that it would be so expensive. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible for outpatient diagnostic tests. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time an ultrasound was received on January 14, 2020. The total amount you are being asked to pay is $396.86. Therefore, we decided that the Plan does not have to waive the deductible for an ultrasound provided by a participating provider on January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

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 services was not filed until October 9, 2020. 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 services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

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 the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

The test at issue in this appeal, ConfirmMDx, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sacroiliac joint injection provided on December 14, 2020.
You asked the Plan to waive the copayment for the sacroiliac joint injection. You say that the copayment for the procedure is too high. You say that you are willing to pay half of the billed copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for each in-network, Medicare-covered outpatient hospital facility visit.
You have been asked to pay a $325 copayment for the sacroiliac joint injection. The sacroiliac joint injection 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 the sacroiliac joint injection provided on December 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on May 7, 2020 to May 11, 2020 by an out of network (OON) provider.
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 the services were rendered by an out-of-network provider without 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 had network providers available who could have provided 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 physical therapy services provided on May 7, 2020 to May 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for over the counter (OTC) smoking patches purchased December 1, 2020.
You asked the Plan to pay for over the counter (OTC) smoking patches. You say that when you were admitted to the hospital, they gave you the brand name patches which helped a lot. When you left the hospital, you chose to purchase the brand name for that reason. The Plan denied your request. The Plan says this item is excluded and is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over the counter (OTC) smoking patches is an OTC item. Therefore, we decided that the Plan does not have to pay for over the counter (OTC) smoking patches purchased December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment for the office visit. You say that the Plan waived copayment through the end of the year. You say that you need an explanation of benefits showing a zero balance. The Plan denied your request. The Plan says only primary care physician costs were waived through the end of the year, therefore 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 $20 copayment for services obtained from a specialist.

You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision care services (99214, 99250).
You asked the Plan to pay for the vision care services. You say that the requested care was necessary. The Plan denied your request. The Plan says vision care services must be obtained from participating providers.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received from a participating provider. We looked at the file and the Plan's rules. The Plan contract clearly states that covered items and services must be obtained from a participating provider. Based on this information, we decided that the Plan's rules for coverage of the vision care services have not been met. Therefore, we decided that the Plan does not have to pay for the vision care services (99214, 99250).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950).

You asked the Plan to pay for the dental service. You say that the filling on this tooth broke off. You say that only a crown could be used to cover the broken off tooth. You also say that you are diabetic and on a limited income. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that the dentist office contacted them and were advised that core build up is a non-covered service.

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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 13, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin Lispro, Oxycodone, Pantoprazole, Docusate
Sodium, Morphine Sulfate, aspirin, and Lisinopril provided from June 19, 2020, to June 20, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you would like these drugs to be
covered. The Plan denied your request. The Plan says these drugs are self-administered, and are not covered
under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin Lispro, Oxycodone,
Pantoprazole, Docusate Sodium, Morphine Sulfate, aspirin, and Lisinopril provided from June 19, 2020, to
June 20, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided by a participating provider on October 2, 2020, to October 6, 2020.
You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you were forced to go to the hospital. You say that you were put into handcuffs. The Plan denied your request. The Plan says the correct copayment has been applied.
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 per day for days 1-5. there is a $0 copayment for additional days for inpatient mental health care. You have been asked to pay a $100 copayment per day for days 1-4 for an inpatient mental health stay. The total amount you are being asked to pay is $400 ($100 x 4 days = $400). Since an inpatient hospital stay was provided, the correct copayment has been applied. An inpatient mental health stay falls within the inpatient mental health 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 an inpatient mental health stay provided by a participating provider on October 2, 2020, to October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 2, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because the services were medically necessary. 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 $265 copayment for ambulance services. You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on November 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit, an x-ray and an injection provided by a participating provider on November 19, 2020.
You asked the Plan to waive the deductible for an office visit, an x-ray and an injection. You say that you do not agree with owing this much. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,300 deductible for an office visit, an x-ray and an injection. The item or service you asked the Plan to waive the deductible for an office visit, an x-ray and an injection falls within the benefit category what is your plan deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,300 deductible for what is your plan deductible. This cost sharing is a contractual obligation that had not been met at the time an office visit, an x-ray and an injection was received on November 19, 2020.The total amount you are being asked to pay is $167.94. Therefore, we decided that the Plan does not have to waive the deductible for an office visit, an x-ray and an injection provided by a participating provider on November 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays and preventive
procedure provided on November 17, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays and preventive procedure. You say that
you would like to appeal these services. The Plan denied your request. The Plan says these services are not
covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.
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
complete series of intraoral x-rays and preventive procedure provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on December 29, 2020.
You asked the Plan to waive the copayment for lab work. You say that you went for your annual wellness exam. You say that you should not have a copayment for that. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $12 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $12 copayment for lab work. When additional services are provided during an annual wellness exam, additional copayments are applied. Lab work falls within the outpatient diagnostic tests/laboratory 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 lab work provided by a participating provider on December 29, 2020.