Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatientmental health care from August 29, 2019 through September 6, 2019.You asked the Plan to waive the copayment forinpatient mental health care. You say that you are appealing your cost-share responsibility for the services you received.The Plandenied 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 were admitted on August 29, 2019 and discharged on September 6, 2019. You were asked to pay a $300 copayment per day from August 29, 2019 through September 1, 2019, days 1-4 of your inpatient stay. There were no copayment charges from September 2, 2019, day 5 of your inpatient mental health care until your day of discharge September 6, 2019. Per your contract there is a $300 copayment per day required for days 1-4. 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 forinpatient mental health care from August 29, 2019 through September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 17, 2019.You asked the Plan to waive the copayment for the office visit. You say that the office advised you to go in. You say that you shouldn't have to pay the bill.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 $10 copayment for in-network PCP office visits. You have been asked to pay a $10 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 inthe Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided on August 2, 2019 to August 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for inpatient services. You say that these services were medically necessary.The Plan denied your request. The Plan says in this case the provider/facility never notified/contacted the Plan, to assure that the service stay was approved being that the member did not go through the ER.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 inpatient services provided on August 2, 2019 to August 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 3, 2019 to September 4, 2019 by an out of network (OON) provider.You asked thePlan to pay forphysician visits. You say that you are appealing.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on July 3, 2019 to September 4, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.You asked the Plan to pre-approve incontinence supplies. You say that the requested supplies are needed.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve incontinence supplies
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit on September 26, 2019.You asked the Plan to waive the copayment foran office visit. You say that you disagree with the charges because you only received laboratory services.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 $15 copayment for each primary care provider visits. You have been asked to pay a $15 copayment for an office visit. An 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 foran office visit on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora LifeVest on April 26, 2019 to May 26, 2019.You asked the Plan to waive the coinsurance fora LiveVest. You say that you are on a fixed income and cannot afford these charges.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 durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for a LiveVest. The total allowed amount is $5,799 ($2,899.50 (April) + $2,899.50 (May) = 5,799). The total amount you are being asked to pay is $1,159.80 ($5,799 x 20% = $1,159.80). A LiveVest falls within the durable medical equipment 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 fora LifeVest  on April 26, 2019 to May 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit on March 12, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you are being charged for denied services and you do not feel like you should be liable. You say you are usually charged $54.71 for the service. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount and that that denied charge has been removed.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 copayment for the specialist office visit. The specialist 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 forthe specialist office visit provided on March 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSo Clean CPAP Cleaner.You asked the Plan to pre-approveSo Clean CPAP Cleaner. You say that it is hazardous to do things involving your hands because you may drop the equipment. When you clean it yourself it has to airdry but it is not sterile and clean that way.The Plan denied your request. The Plan says this service is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approveSo Clean CPAP Cleaner
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the two prophylaxes, periodic oral evaluation, two
amalgams, and extraction provided from February 4, 2019 to October 7, 2019.
You asked the Plan to pay for the prophylaxes, periodic oral evaluation, amalgams, and extraction. You say
that when you signed up for this insurance you did not receive any information about the dental plan. The Plan
denied your request. The Plan says your dental benefits are limited to the listed dental services when they are
rendered by a participating general dentist. The Plan also says these providers are out-of-network and your plan
does not provide any benefits for services performed by an out-of-network provider.
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 two prophylaxes, periodic oral evaluation, two amalgams, and extraction provided from February 4, 2019 to
October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 29, 2019 through November 3, 2019 provided by an out-of-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that you had not choice of the facility that you were transported to as you were in severe distress.The Plan denied your request. The Plan says you have out-of-network benefits and 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 show that you received inpatient hospital care from October 29, 2019 through November 3, 2019 provided by an out-of-network provider. At the time of services rendered you had not met your $750 deductible; therefore, you have been asked to pay $527.90 for the services to apply to your deductible. You then met your deductible and are asked to pay 35% coinsurance for your 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 from October 29, 2019 through November 3, 2019 provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe medical services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided to the enrollee by a network provider.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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on August 8, 2019 by an out ofnetwork (OON) provider.You asked the Plan to pay forphysician services. You say that your provider cannot deny any medical services that were essential for patient health treatment while hospitalized.The Plan denied your request. The Plan says the referring nursing facility is out-of-network. The Plan says that no prior authorization was obtained for 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 forphysician services provided on August 8, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two prophylaxes, periodic oral evaluation, two
amalgams, and extraction provided from February 4, 2019 to October 7, 2019.
You asked the Plan to pay for the prophylaxes, periodic oral evaluation, amalgams, and extraction. You say
that when you signed up for this insurance you did not receive any information about the dental plan. The Plan
denied your request. The Plan says your dental benefits are limited to the listed dental services when they are
rendered by a participating general dentist. The Plan also says these providers are out-of-network and your plan
does not provide any benefits for services performed by an out-of-network provider.
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 two prophylaxes, periodic oral evaluation, two amalgams, and extraction provided from February 4, 2019 to
October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on August 26, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you do not know why the Plan is not paying for these types of services.The Plan denied your request. The Plan says the correct copayment has been applied to the service that was provided.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 $175 copayment for outpatient diagnostic tests/complex diagnostic radiology. You have been asked to pay $114.94 which is less than your copayment amount of $175 for a CT scan. A CT scan falls within the outpatient diagnostic tests/complex diagnostic radiology 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 fora CT scan provided on August 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing (95999) provided on May 29, 2019.You asked the Plan to pay fortrain of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says payment of this service is bundled into other services.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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continued referral for an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plan says the doctor's notes should show that the required care is not available in the plan's group of contracted doctors.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 networkprovider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. There is no evidence of any medical necessary for continuity of care, as the provider did not submit records. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea continued referral for an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on May 2, 2019.
You asked the Plan to pay for the subsequent hospital care. You say that the services that were performed in the hospital were emergent at the time of the enrollee's visit. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 subsequent hospital care provided on May 2, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided August 29, 2019 to September 9, 2019. You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient services were medically necessary.The Plan denied your request. The Plan says that services could have been provided on an outpatient basis.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted with chest pain, recurrent falls, and lightheadedness. The evaluation revealed severe spinal stenosis and neuroclaudication. The record showed that at the time of inpatient admission the admitting physician reasonably expectedthat the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided August 29, 2019 to September 9, 2019. 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.