Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits rendered on February 17, 2020 and February 28, 2020.
You asked the Plan to waive the copayment for these services. You say that you would like the copayments waived. The Plan denied your request. The Plan says the copayments were 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 $35 copayment per specialist office visit.
Review of the file shows that you had a specialist office visit on February 17, 2020 and February 28, 2020. You have been asked to pay a $35 copayment per visit for these services, for a total of $70. These services fall within the specialist office visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visits rendered on February 17, 2020 and February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 29, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you were advised you would be reimbursed. You say that you should be paid in full. 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 $275 copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine and stress tests). You have been asked to pay a $275 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that you were reimbursed $125 ($400-$275 = $125). 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 MRI provided on January 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 15, 2019 to October 21, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee received no skilled nursing services during this time frame that would be considered skilled services by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.
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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 15, 2019 to October 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on February 3, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this service is not covered for screening purposes.
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 genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 29, 2019 to November 27, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. 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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 29, 2019 to November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 the drug testing services provided on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a digital breast tomosynthesis (77062) provided February 21, 2020.
You asked the Plan to waive the copayment for the digital breast tomosynthesis. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $150 copayment for diagnostic radiology. You have been asked to pay a $150 copayment for the digital breast tomosynthesis. The digital breast tomosynthesis falls within the 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 for a digital breast tomosynthesis (77062) provided February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 the drug testing services provided on February 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 5, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 laboratory services provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from October 7, 2019 to
October 28, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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 physician's services provided from October 7, 2019 to October
28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided
from February 15, 2020 to February 20, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are not
responsible for the second copay. The Plan denied your request. The Plan says that the inpatient hospital cost
sharing will apply each time you are admitted.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for days 1-5 of inpatient hospital care.
You have been asked to pay a $1,625 copayment for the inpatient hospital services. The inpatient hospital
services fall within the days 1-5 of inpatient hospital 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 the inpatient hospital services provided from February 15, 2020 to February 20,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits provided from
January 10, 2020 to February 7, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that you are appealing the
claims because you saw a nurse practitioner for these services. You had the medical records sent in showing
you were seen by a nurse practitioner. 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 $40
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's
office.
You have been asked to pay a $40 copayment for each of the specialist office visits. The specialist office visits
fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record
shows you were seen by a nurse practitioner who specializes in Obstetrics & Gynecology.
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 visits provided from January 10, 2020
to February 7, 2020.We decided that the Plan does not have to waive the copayments for the specialist office visits provided from
January 10, 2020 to February 7, 2020.
You asked the Plan to waive the copayments for the specialist office visits. You say that you are appealing the
claims because you saw a nurse practitioner for these services. You had the medical records sent in showing
you were seen by a nurse practitioner. 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 $40
copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a
nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's
office.
You have been asked to pay a $40 copayment for each of the specialist office visits. The specialist office visits
fall within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The record
shows you were seen by a nurse practitioner who specializes in Obstetrics & Gynecology.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-complete series x-ray (D0210) provided November
20, 2019.
You asked the Plan to pay for the dental services. You say that it is your understanding that dental x-rays were
included in your coverage. Your dentist's office indicated that those taken were for preventative purposes and
most insurances covered them. The Plan denied your request. The Plan says this service is not covered under
the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The health plan contract
specifically says that only 1 bitewing x-ray is covered by the plan.
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 intraoralcomplete
series x-ray (D0210) provided November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered on January 23,
2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment 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
copayment per visit to a specialist.
Review of the file shows that you received an allergy shot during a specialist visit on January 23, 2020. Per
your contract with the Plan, there is a $20 copayment per visit to a specialist. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these
services was $10.36. Given that the allowed amount was less than the $20 copayment, you have been asked to
pay $10.36 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the office visit rendered on
January 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were at a swim meet when you began
to experience cramps, which you later found out was a result of food poisoning. You say that some of the
people nearby helped you to a seat and called for emergency medical assistance. The responders came and
checked your vitals which showed that you were healthy. You say that you declined transportation to the
hospital and decided to drive yourself home. You stated that it was an emergency situation and that you had no
control whether the ambulance was called or not. You say that you did not wish to further prolong an already
bad evening with a trip to the hospital since you knew why you had fallen ill and could handle it at home. The
Plan denied your request. The Plan says these services are not a covered benefit.
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 January 26, 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 the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the post stabilization inpatient care provided from November
5, 2019 to November 6, 2019.
You asked the Plan to pay for the post stabilization inpatient care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that the enrollee could have been transferred to a Plan
facility.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 the post stabilization inpatient care. Our
reviewer says that that inpatient care was not medically reasonable and necessary for the enrollee in this case.
The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was
not stable for transfer on any dates of service. Our physician reviewer found that the enrollee was
hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan
facility for observation/admission level of care services after the emergency room evaluation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the post stabilization inpatient care have not been met. Therefore, we decided
that the Plan does not have to pay for the post stabilization inpatient care provided from November 5, 2019 to
November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection provided on November 13,
2019.
You asked the Plan to waive the cost share for the injection. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received a Medicare Part B injection on the date of service at issue in this
appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.
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.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an injection on
November 13, 2019. You have been asked to pay a 20% coinsurance for the injection, totaling $536.22. 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 cost share for the injection provided on November 13, 2019.