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

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 28, 2019 through September 5, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be responsible for the second facility copayment. 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 were admitted on August 28, 2019 and discharged on September 5, 2019. You were asked to pay a $225 copayment per day from August 28, 2019 through September 1, 2019, days 1-5 of your inpatient stay. There were no copayment charges from September 2, 2019, day 6 of your inpatient hospital care until your day of discharge September 5, 2019. Per your contract there is a $225 copayment per day required for days 1-5, per in-network admission. 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 August 28, 2019 through September 5, 2019 provided by an in-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on January 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a colonoscopy. You say that the member did not present the correct information. You say that the PCP is unwilling to obtain authorization on the enrollee's behalf. The Plan denied your request. The Plan says no prior authorization was 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 for a colonoscopy provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the colonoscopy provided on December 9, 2019.
You asked the Plan to reduce the copayment for the colonoscopy. You say that you do not believe this was an outpatient surgery. You say you believe you should have a $25 copayment for diagnostic services. 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 $100 copayment for Medicare-covered surgery or services at an out-of-network outpatient hospital or ambulatory surgical center, including but not limited to other facility charges and physician or surgical charges. You have been asked to pay a $100 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows an admitting diagnosis of a benign neoplasm of ascending colon, which makes the colonoscopy diagnostic in nature.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the colonoscopy provided on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that this is a medically necessary item
that is expected to help in standing and assist in blood flow. The Plan denied your request. The Plan says this
item is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
non-covered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns and two core buildups, including any pins when required provided on January 27, 2020.
You asked the Plan to pay for the crowns and core buildups. You say that your dental office failed to check your coverage prior to these services being rendered. You also say that you are on a limited income and are unable to pay this bill. The Plan denied your request. The Plan says these services are not covered.
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 two crowns and two core buildups, including any pins when required provided on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 21, 2020 by an out of network (OON) provider.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 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 the physician services provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services provided on February 26, 2020.
You asked the Plan to waive the copayment for outpatient mental health services. You say that you disagree with the charges. 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 $50 copayment for out-of-network outpatient mental health care provided in a specialist's office. The record shows that you received outpatient mental health services from an out-of-network specialist on February 26, 2020. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for outpatient mental health services. Outpatient mental health services fall within the outpatient mental health 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 outpatient mental health services provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99232, 99223) provided from February 25, 2019 to March 4, 2019.You asked the Plan to pay for hospital care. You say that this should be accepted because it was originally submitted to Original Medicare.The Plan denied your request. The Plan says this 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 hospital care was not filed until March 5, 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 hospital care (99232, 99223) provided from February 25, 2019 to March 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 6, 2019 to December 17, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you depend on the hospital to obtain prior authorization.The Plan denied your request. The Plan says no prior authorization was 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 topay 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 physician services provided on December 6, 2019 to December 17, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora screening mammogram (77063, 77067) provided November 27, 2019.You asked the Plan to pay for the screening mammogram. You say that the service was medically necessary and should be covered.The Plan denied your request. The Plan says the benefit for screening mammograms was exhausted at the time the service was provided.The Plan must follow Medicare rules. Medicare rules say that a screening mammogram is covered once a year for women over 39. We looked at the file and Medicare rules. The records show a screening mammogram was already provided in June, 2019. Based on this information, we decided that Medicare rules for coverage of the screening mammogram have not been met.Therefore, we decided that the Plan does not have to pay fora screening mammogram (77063, 77067) provided November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from January 17, 2020 through January 18, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that you were not advised of your doctors order to keep you overnight. You say that this caused a delay for a proper diagnosis. 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 $175 for each Medicare-covered outpatient hospital observation stay at a hospital facility. You have been asked to pay a $175 copayment for the observation stay. The observation stay falls within the "Outpatient Hospital Observation" benefit category. The records show that you were admitted to outpatient observation. 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 observation stay provided from January 17, 2020 through January 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral
periapical x-ray, and comprehensive oral evaluation provided on January 27, 2020 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and
comprehensive oral evaluation. You say that a Plan representative gave you permission to get a second opinion
from this provider. You also say that you feel you did what you were instructed to do by the Plan. The Plan
denied your request. The Plan says the treating provider is OON and the services were not authorized. The Plan
also says that unless your plan approves it, the Plan only covers services provided by your assigned dentist.
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 OON. The Plan confirmed that there is no record that you made any calls to the
Plan after December 16, 2019, nor were you authorized to have a second opinion with this provider. Therefore,
we decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral
periapical x-ray, and comprehensive oral evaluation provided on January 27, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for adult size pull on (T4526) and disposable liner/shield/pad
(T4535) purchased January 23, 2020 to March 13, 2020.
You asked the Plan to pay for incontinence supplies. You say that you were not aware you would have any
charges for the these supplies. The Plan denied your request. The Plan says incontinent supplies are not covered
by Medicare or the plan.
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 pay for adult size pull on (T4526) and
disposable liner/shield/pad (T4535) purchased January 23, 2020 to March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visit (99213) provided on January 28, 2020.You asked the Plan to waive the deductible forthe office visit. You say that you would like reconsideration because you had the same service last year at no cost.The Plan denied your request. The Plan did not address the issue of the deductible for this service.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible before they will begin to pay their share. The Plan has followed Medicare rules by clearly disclosing in the contract thatthere is a $1,000 deductible before they will begin to pay their share. The record indicates that you have not yet reached your deductible amount so the charge of $70.42 has been applied appropriately. This cost sharing is a contractual obligation that had not been met at the time the office visit was received.Therefore, we decided that the Plan does not have to waive the deductible forthe office visit (99213) provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an adjustable mattress and bathroom chair.
You asked the Plan to pre-approve the requested items. You say that you have extreme difficulty getting out of bed, and getting to the bathroom. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The file does not show that you are confined to a bed or room as defined by Medicare rules. The file does not show that you meet the coverage criteria for a mattress. Therefore, we decided that the Plan does not have to pre-approve an adjustable mattress and bathroom chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on February 4, 2020.
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 Medicare says non-urgent services should be from network providers who are contracted with
the healthplan and listed in the Provider Directory.
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 lab services provided to the enrollee on February
4, 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 would like to appeal the Plan's denial of the ambulance response services. You say that it was necessary for you to have medical professionals to take care of the situation after you had fainted. You stated that you were not transported by the ambulance because you felt okay after the paramedics had arrived and you did not want to increase your medical costs. You say that you are unable to afford the medical expenses of the ambulance response services.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 December 1, 2019. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for diagnostic mammograms and ultrasounds provided on February 21, 2020.You asked the Plan to waive the deductible for diagnostic mammograms and ultrasounds. You say that you disagree with the charges for the mammogram screening.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. Your contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. The medical records show that you received diagnostic mammograms and ultrasounds on February 21, 2020. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $328.09. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time diagnostic mammograms and ultrasounds was received on February 21, 2020.Therefore, we decided that the Plan does not have to waive the deductible for diagnostic mammograms and ultrasounds provided on February 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on January 17, 2020.You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules.There are no medical records, around the date of the order, supporting medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on January 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for professional consult, fitting and programming service (99199) and hearing aid, digital, monaural, bte (V5257) provided on December 10, 2019 provided by an out-of-network provider.You asked the Plan to pay for the services. You say that the services were medically necessary.The Plan denied your request. The Plan says you do not have out-of-network benefits.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.Review of the file shows that you purchased the hearing aids from an out-of-network provider. The hearing aids are denied due to the provider being out-of-network with the supplemental hearing plan. The professional consult, fitting and programming service (99199) is denied because the services are not covered by Medicare or your supplemental hearing plan.Therefore, we decided that the Plan does not have to pay for professional consult, fitting and programming service (99199) and hearing aid, digital, monaural, bte (V5257) provided on December 10, 2019 provided by an out-of-network provider.