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

We decided that the Plan does not have to waive the copayment for the ambulance transport and pay forthe additional ambulance miles provided on May 3,2019.You asked the Plan to waive the copayment for the ambulance transport and pay forthe additional ambulance miles. You say that you were not happy with the services provided and you only rode in the ambulance because you were told you had to.The Plan denied your request. The Plan says the copayment applied correctly and non-emergency transportation by ambulance is only covered to the closest facility that can provide 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 $250 copayment for Ambulance services. The rules also say that Medicare pays for ambulance transports onlywhen they meet certain origin and destination requirements.
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 copayment 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 additional ambulance milesyou have asked the Planto pay for are ambulance transport services beyond the distance to the nearest appropriate facility. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport and pay forthe additional ambulance miles providedon May 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe limited oral evaluation provided on August 16, 2019.You asked the Plan to pay forthese services. You say that this should be paid for because you were not informed it was not covered.The Plan denied your request. The Plan says that this is not a 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation provided on August 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services for an eye examination provided.
You asked the Plan to waive the copayment for the physician's services for the eye examination. You say that that you went to your doctor for the diabetic retinal exam and you were advised this exam was free per a flyer you received from the Plan. You say that you do not feel that you should be liable for a $50 copay for this service. The Plan denied your request. The Plan says according to the medical records, the provider identified that you have low risk, open-angle glaucoma bilaterally and endothelial corneal dystrophy. This constitutes a medical eye exam.
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 copayment for vision care, medical eye exam. You have been asked to pay $50 copayment for the physician's services for an eye examination. The physician's services for an eye examination falls within the vision care, medical eye exam 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 physician's services for an eye examination provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on August 20, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that this was an outpatient procedure as you were not admitted and left on the same day. The Plan denied your request. The Plan says their standard procedure for knee replacements is to approve as inpatient level of care in case of any complications.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). It is under the doctor's digression if a member is stable and ready for discharge on the same day. The Plan has called the healthcare billing department multiple times to confirm this was an inpatient procedure. The authorization provided to them was for inpatient level of care and that is how they billed. You are asked to pay a $350 copayment for the inpatient hospital 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 waive the copayment for inpatient hospital care provided on August 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided.
You asked the Plan to waive the copayment for the ambulance ride. You say that you cannot afford the copayment for the ambulance. 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 $225 copayment for each Medicare-covered one-way trip in a ground ambulance. You have been asked to pay a $225 copayment for the ambulance ride. The ambulance ride 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 ride provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from September 22, 2019 through September 26, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should only be charged for five days instead of six. When you left the hospital you were never informed that the days would not run consecutively for the stay. You state you were told there would be no second admittance when you moved because the right equipment was not at one facility, but at another. You state it was not per your request. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you received inpatient hospital care from September 22, 2019 through September 26, 2019. You were asked to pay a $370 copayment per day from September 22, 2019 through September 25, 2019, days 1-4 of your inpatient hospital care. You were discharged on September 26, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $370 copayment per day required for days 1-5. For inpatient hospital care, the cost-sharing described above applies each time you are admitted to the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided from September 22, 2019 through September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and X-ray provided by the practice from April 1, 2019 to May 14, 2019.
You asked the Plan to waive the copayments for an inpatient hospital stay and X-ray. You say that you feel that the charges are too high. 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 $200 copayment for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $75 copayment for outpatient x-rays. You had an inpatient hospital stay from April 1, 2019 to April, 4, 2019. Therefore, you are responsible to pay a $200 copayment for days 1-3 (April 1, 2019 to April 3, 2019). $200 (copayment) x 3 (inpatient days) = $600.00. You had an X-ray on April 1, 2019. Therefore, you are responsible to pay the $75 copayment. The total amount you owe is: $675.00. You have been asked to pay the total copayment amount of $675.00 for an inpatient hospital stay and X-ray. An inpatient hospital stay falls within the inpatient hospital care benefit category. An X-ray 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 copayments for an inpatient hospital stay and X-ray provided by the practice from April 1, 2019 to May 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transportation services you received on February 1, 2019.
You asked the Plan to waive the copay for the transportation services. You say that the ambulance ride was only need due to medical malfeasance. The Plan denied your request. The Plan says the copay was applied based on 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 a $275 copay for Medicare-covered ambulance services per day. You have been asked to pay a $275 copay for the ambulance services. The 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 copay for the ambulance transportation services you received on February 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe Oncology prostate gene expression profile provided to the enrollee on July 30, 2019.You asked the Planto pay forthe testing. You say that  The Plandenied your request. The PlansaysThe Plan must follow Medicare rules. Medicare rules say that the EPI gene test is considered investigational.The test at issue in this case was considered investigational at the time of service. Based on thisinformation, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forthe Oncology prostate gene expression profile provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for practitioner services provided on March 25, 2019 and May 6, 2019.You asked the Plan to waive the copayments for practitioner services. You say that you have never had to pay for this procedure. You say that you cannot pay.The Plan denied your request. The Plan says the copayments 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 $30 copayment for each Medicare-covered specialist visit. Covered services include consultation, diagnosis, and treatment by a specialist.You have been asked to pay a $30 copayment for each visit. Practitioner services fall 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 copayments for practitioner services provided on March 25, 2019 and May 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy, premolar tooth (excluding final restoration) (D3320 x 2) provided on July 25, 2019.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says your EOC does not provide coverage for root canal treatment.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 endodontic therapy, premolar tooth (excluding final restoration) (D3320 x 2) provided by on July 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI of the head (70544) provided on August 30, 2019.You asked the Plan to pay for the MRI of the head. You say that you would like reconsideration as separate procedures were performed. The Plan denied your request. The Plan says the documentation received does not match the date of service of August 30, 2019.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 70544 is not supported in the record. Specifically, the record does not indicate that these services were rendered on the billed date of service of August 30, 2019. Based on this information, we decided that Medicare rules for coverage of the MRI of the head have not been met. Therefore, we decided that the Plan does not have to pay for an MRI of the head (70544) provided on August 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist on August 15, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you were supposed to see a kidney doctor not a urologist. The Plan denied your request. The Plan says an office visit with a specialist has a $30 copayment per visit.
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 $30 copayment for physician services. You have been asked to pay a $30 copayment for an office visit. This service falls within the 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 copayment for an office visit with a specialist on August 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on June 20,2019.You asked the Plan to waive the copayment forthe CT scan. You submitted your bill for review. You say that you should not be liable.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 $225 copayment for advanced imaging services from an in-network provider. If advanced imaging services are received as part of an emergency department evaluation then you will only pay the advanced imaging copayment, not the emergency room copayment. You have been asked to pay a $225 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 forthe CT scan provided on June 20, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus and diphtheria vaccine provided on July 26, 2019.
You asked the Plan to pay for a tetanus and diphtheria vaccine. You say that the enrollee was at risk. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus and diphtheria vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus and diphtheria vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus and diphtheria vaccine provided on July 26, 2019.
Benefits for a tetanus and diphtheria vaccine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Infliximab Injection provided on May 15, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you would like a onetime waiver. The Plan denied your request. The Plan says the coinsurance was 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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injection. the injection falls 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 Infliximab Injection provided on May 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit and x-ray provided on August 7, 2019.You asked the Plan to waive the copayments for the specialist office visit and the x-ray. You say that you should not be responsible for the copayments. 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 $50 copayment for each in-network Medicare-covered visit with a specialist and a $35 copayment per day, per provider, for in-network Medicare-covered x-ray services. You have been asked to pay a $50 copayment for the specialist office visit and a $35 copayment for the x-ray. ($50 + $35 = $85). The specialist office visit falls within the "Physician and Practitioner services, including doctor's office visits" benefit category. The x-ray 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 copayments for the specialist office visit and x-ray provided on August 7, 2019.Your complaint about the provider misdiagnosing your corn is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tetanus vaccine rendered to you by the provider on September 6, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the vaccine is nota covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness relatedto these services.Therefore, we decided that the Plan does not have to pay forthe tetanus vaccine rendered to you on September 6, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency medicine services (CPT 99285) provided to the enrollee on April 26, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the denied code was 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.We find that CPT code 99285 is not supported in the medical record. Specifically, only one evaluation and management service is allowed for the same date of service by the same provider. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for emergency medicine services (CPT 99285) provided to the enrollee on April 26, 2019.