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

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided by a participating provider on January 17, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you think this is way too high. 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 a 20% coinsurance for Medicare Part B prescription drug/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,750.11. The total amount you are being asked to pay is $350.02 ($1,750.11 x 20% = $350.02). An injection falls within the Medicare Part B prescription drug/in-network 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 chemotherapy provided by a participating provider on January 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 21, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 laboratory services at issue in this appeal were 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 provided on January 21, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0431, A0436) provided on November 17, 2019.
You asked the Plan to pay for ambulance services. You say that the enrollee was no longer in hospice at the time of service. The Plan denied your request. The Plan says payment for these services is the responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 1, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services (A0431, A0436) provided on November 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ultrasound provided on August 25, 2020.You asked the Plan to waive the copayment foran ultrasound. You say that due to your history of cancer you feel that this test should be considered preventative.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 ultrasounds. You received an ultrasound on August 25, 2020. An ultrasound is considered a diagnostic service, not preventative. Therefore, you are responsible to pay the allowed amount of $109.40, which is less than the $200 copayment.  You have been asked to pay $109.40 for an ultrasound. An ultrasound 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 foran ultrasound provided on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug test (G0483) provided on February 24, 2020.You asked the Plan to pay forthe drug test. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the place of service on the claim does not reflect the location of the patient when the specimen was obtained.The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.We find that CPT code G0483 is not supported in the record. Specifically, the record indicates that the specimen was obtained in an office setting. The claim was billed with a laboratory place of service code. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met.Therefore, we decided that the Plan does not have to pay forthe drug test (G0483) provided on February 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on April 12, 2020.
You asked the Plan to waive the copayment for ambulance transport. You say that you were admitted to the hospital however were transported by ambulance to a recovery center afterward. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 each one-way ambulance trip. You have been asked to pay $200 copayment for ambulance transport. Ambulance transport falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation provided on April 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (S9328) provided to the enrollee from March 15, 2018 to June 27, 2018.
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 this code is not payable by Original Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy services (S9328) provided to the enrollee from March 15, 2018 to June 27, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest X-ray provided on February 18, 2020.
You asked the Plan to pay for the chest X-ray. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.
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 and the ordering provider are not network providers with the Plan. The Plan did not pre-approve the services at issue. 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 a chest X-ray provided on February 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on June 9, 2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that this copayment is too high. 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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for an ambulance trip. The correct copayment has been applied to the ambulance service that was provided. An ambulance trip 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 an ambulance trip provided by a participating provider on June 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99222) provided August 2, 2019.
You asked the Plan to pay for the physician services. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim was not filed timely.
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 physician services was not filed until August 20, 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 physician services (99222) provided August 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from July 31, 2020, to August 20, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you feel that the enrollee should not be responsible for the charges due to the quality of care received. The Plan denied your request. The Plan says the claims were processed 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 $20 copayment for each admission for days 1-20 and a $0 copayment for days 21-100 for SNF care. The enrollee had a SNF stay from July 31, 2020, to August 20, 2020. Therefore, the enrollee is responsible to pay a $20 copayment for days 1-20 (July 31, 2020, to August 19, 2020). $20 (copayment) x 20 (SNF days) = $400. The enrollee has been asked to pay the total copayment amount of $400 for a SNF stay. A SNF stay falls within the SNF care 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 a SNF stay provided from July 31, 2020, to August 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the tracheostomy supplies rendered on August 14, 2020.
You asked the Plan to waive the coinsurance for these services. You say that another company sells these at a lower price and you don't like the price the Plan is charging. 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 in-network Medicare-covered durable medical equipment.
Review of the file shows that you received tracheostomy supplies on August 14, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $102.80. These services fall within the in-network Medicare-covered 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 for the tracheostomy supplies rendered on August 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory tests provided on August 28, 2020.You asked the Plan to waive the copayment forlaboratory tests. You say that you were told that you do not pay a copayment for laboratory services if they are provided during an office visit. You state that the laboratory services were taken a week prior to your visit so that the results could be discussed in person.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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall 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 forlaboratory tests provided on August 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive dental service (D1999) provided on August 24, 2020.
You asked the Plan to pay for the dental service. You say that cleanings have always been covered by insurance. You say that you realized that your dentist recently decided to become out of network. You also say that this service should still be covered. The Plan denied your request. The Plan says the unspecified preventive service is not listed as 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 for the unspecified preventive dental service (D1999) provided on August 24, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on June 8, 2020.
You asked the Plan to pay for lab tests. You say that this testing enabled the enrollee's treating physician to determine the optimal treatment pathway for the enrollee. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because progress notes from the ordering provider are needed in order to determine the clinical utility of the testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on June 8, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and caries risk assessment provided on August 11, 2020.
You asked the Plan to pay for the comprehensive oral evaluation and caries risk assessment. You say that you would like the payment approved so that you can proceed with getting dentures. The Plan denied your request. The Plan says the comprehensive oral evaluation exceeds the maximum allowed per period. The Plan also says that the caries risk assessment is not a covered benefit.
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, caries risk assessment is not among those covered under this benefit. The contract clearly says that you are limited to 1 oral exam every 6 months. The record shows that you received an oral exam on July 30, 2020, and your oral exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and caries risk assessment provided on August 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic test provided a participating provider on October 8, 2020.
You asked the Plan to waive the copayment for an auditory test. You say that you do not agree with this copayment 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 outpatient diagnostic tests/ diagnostic tests. You have been asked to pay a $10 copayment for an auditory test. An auditory test falls within the outpatient diagnostic tests/ diagnostic 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 a diagnostic test provided a participating provider on October 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service with no transportation provided on September 12, 2020.
You asked the Plan to pay for ambulance service. You say that the ambulance did not take you to the emergency room, but you thought your insurance would cover this service. The Plan denied your request. The Plan says the denial of payment for this service is correct.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 12, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance service with no transportation provided on September 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on August 17, 2020, and August 23, 2020.
You asked the Plan to waive the copayments for ambulance services. You say that you feel that the charges are outrageously high. The Plan denied your request. The Plan says the claims were processed 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 $265 copayment for ambulance services. The enrollee received ambulance services from August 17, 2020, to August 23, 2020, for a total of two trips. Therefore, the enrollee is responsible to pay a $265 copayment for each ambulance trip. The total amount the enrollee owes is $530. The enrollee has been asked to pay the total copayment amount of $530 for ambulance services. Ambulance services fall within the ambulance services 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 copayments for ambulance services provided on August 17, 2020, and August 23, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forlab services (82607) provided March 2, 2020.You asked the Plan to pay forthe lab services. You say that the service was medically necessary.The Plan denied your request. The Plan says that the service billed can only be payed once every 12 months unless a deficiency disorder or malabsorption syndrome diagnosis is listed.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In their denial, theplan did not cite or reference the CMS or plan policy used to make their determination. Insufficient documentation was provided to support the denial.Therefore, we decided that the Plan has to pay forlab services (82607) provided March 2, 2020.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.