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

We decided that the Plan does not have to waive the coinsurance for the periodontal cleaning services received
on January 25, 2021.

You asked the Plan to waive the coinsurance for the periodontal cleaning services. You say that you would like
the plan to reconsider their decision. The Plan denied your request. The Plan says the claim has been processed
correctly per your plan 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). Your contract with the Plan clearly says that you must pay 70%
coinsurance for periodontal maintenance.

You have been asked to pay 70% coinsurance for the periodontal cleaning services. The periodontal cleaning
services falls within the periodontal maintenance 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 periodontal cleaning services received on January 25, 2021.
Appeal type: ER
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing and pay for observation services and self-administered drugs.
You say that you are appealing these charges. The Plan says that the cost-sharing amounts the enrollee is being
charged are correct, and the denial of payment for self-administered drugs is correct.

We decided that the Plan has to reduce the cost-sharing for observation services provided from
September 14, 2020, to September 17, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay
$150 co-payment for in-network observation services provided in a single stay. These observation services were
provided in a single stay; therefore, only one co-payment would apply to the observation services provided in
this stay.

The Plan says the enrollee must pay $452.17 for observation. Based on the plan contract, however, the enrollee
cannot be asked to pay more than $150 co-payment for observation. Therefore, we decided that the Plan has to
reduce the cost-sharing for observation services from $452.17 to $150 co-payment.

We also decided that the Plan does not have to waive the cost-sharing and pay for observation services
and self-administered drugs provided from September 14, 2020, to September 17, 2020.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
co-payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay $150 co-payment for in-network observation. 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
waive the cost-sharing and pay for observation services and self-administered drugs.

Benefits for 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.

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 for the outpatient office visit (99203) x-ray spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (72083) chiropractic manipulative treatment (98942) provided December 17, 2020 to December 21, 2020.
You asked the Plan to pay for the chiropractic services. You say that you were told by a plan representative that the plan covers chiropractic services. Now you got a statement telling you they don't cover it at all. This is not fair because you wouldn't have went if you had known. The Plan denied your request. The Plan says maintenance care, x-rays, labs, and any other service done within a chiropractor's office is not covered. The $20 copayment for the chiropractic manipulative services provided 12/21/20 applied correctly per the EOC.
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 for each Medicare covered visit.
You have been asked to pay $20 for the chiropractic manipulative treatment (98942). The chiropractic manipulative treatment (98942) falls within the Chiropractic 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.
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 services at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) x-ray spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (72083) provided December 17, 2020 to December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on May 14, 2019, by an OON
provider.
You asked the Plan to pay for office services. You say that your primary care provider gave you a referral for
these services, and you were not aware that this provider was not part of the Plan network. 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 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 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 office services provided on May 14, 2019, by an
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on
December 2, 2020.

You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify
eligibility and to obtain proper authorization. You say that the doctor should not be penalized, and the claim
should be considered for payment. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan and the services were not approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 home visit provided by an out-of-network
provider on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the naturopathy office visit provided on January 4, 2021.

You asked the Plan to pay for the naturopathy office visit. You say that you chose the more expensive plan so this service would be covered. The Plan denied your request. The Plan says your plan does not cover naturopathy services.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The plan you are in does not cover naturopathy services therefore you must pay the full cost. Based on this information, we decided that Medicare rules for coverage of the naturopathy office visit have not been met. Therefore, we decided that the Plan does not have to pay for the naturopathy office visit provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction (CPT code 92015) and ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program (CPT Code 92004) provided to the enrollee on October 13 2020, by an out-of-network provider.

You asked the Plan to pay for the services. You say that the provider was called in for an optometry consultation on this enrollee. The Plan denied your request. The Plan says this provider is out-of-network, and the services were not urgent or emergent, nor were they approved in advance.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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. Furthermore, refraction is not separately reimbursed as part of a routine eye exam or as part of a medical examination and evaluation with treatment/diagnostic program. Therefore, we decided that the Plan does not have to pay for eye refraction (CPT code 92015) and ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program (CPT Code 92004) provided to the enrollee on October 13 2020, by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services provided from June 18, 2020, to July 9,
2020.

You asked the Plan to pay for the infusion services. You say that the services should be covered. The Plan
denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in
which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the infusion services provided from June 18, 2020, to July 9,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by participating providers on January 18, 2021, to February 2, 2021.
You asked the Plan to waive the copayment for vision services. You say that you do not agree with these services. 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 $10 copayment for vision care. You have been asked to pay a $10 copayment for vision services. The total amount you are being asked to pay is $20 ($10 x 2 visits = $20). Vision services fall within the vision 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 vision services provided by participating providers on January 18, 2021, to February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on March 11, 2020.
You asked the Plan to waive the coinsurance for the office visit. You say that you feel this provider should be in network. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for Out of Network Physician services. You have been asked to pay 50% coinsurance for the office visit. The office visit falls within the Out of Network Physician 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 coinsurance for the office visit provided on March 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery performed at an out of network facility on January 14, 2021.

You asked the Plan to waive the coinsurance for out of network outpatient surgery. You say that you were not aware that the facility was out of network. The Plan denied your request. The Plan says the correct coinsurance was 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 30% coinsurance for each Medicare-covered out of network outpatient surgery service. 

You have been asked to pay 1,077.67, or 30% of the Medicare-allowed amount of $3,592.26, for out of network outpatient surgery. 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 outpatient surgery performed at an out of network facility on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a screening colonoscopy (G0105) provided on January 4, 2021, by an out of network provider.

You asked the Plan to pay for a screening colonoscopy. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 a screening colonoscopy (G0105) provided on January 4, 2021, by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 12, 2020 provided on June 12, 2020 by a non-participating 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 a non-participating 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 laboratory services rendered on June 12, 2020 provided on June 12, 2020 by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (43239) provided February 25, 2021.

You asked the Plan to waive the copayment for the esophagogastroduodenoscopy. You say that the plan should pay the $200 copay. You await payment. If you, you will repeatedly apply for the same. The Plan denied your request. The Plan says the claim processed and the correct copayment was applied per the Evidence of Coverage.

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 $200 copayment for procedures performed at an in-network ambulatory surgical center. 

You have been asked to pay $200 copayment for the esophagogastroduodenoscopy. The esophagogastroduodenoscopy 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 esophagogastroduodenoscopy (43239) provided February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 24, 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 the testing is not covered.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the laryngoscopy and chest x-ray provided on December 15, 2020.
You asked the Plan to reduce the copayment for the laryngoscopy and chest x-ray. You say that you would like the Plan to reduce the copayment to an emergency care copayment. The Plan denied your request. The Plan says you were charged the copayments 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 $10 copayment for Outpatient Diagnostic Test standard x-ray services and a $250 copayment for Outpatient Surgery.
You have been asked to pay a $10 copayment for standard x-ray services and a $160.26 copayment for Outpatient Surgery for the laryngoscopy. The allowed amount for the laryngoscopy was $160.26 which is less than your required copayment. This claim was not submitted as Emergency Care. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the laryngoscopy and chest x-ray provided on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on January 14, 2021 by an out of network (OON) provider.

You asked the Plan to pay for office services. You say that you are appealing with supporting 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 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 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 office services provided on January 14, 2021 by an out of network (OON) provider.