Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and each additional intraoral periapical x-ray provided on February 5, 2020.
You asked the Plan to pay for the intraoral periapical x-rays. You say that you were misled by a customer care representative. The Plan denied your request. The Plan says these services are not covered 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. 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 first intraoral periapical x-ray and each additional intraoral periapical x-ray provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the chemotherapy drugs provided from
January 13, 2020 to January 20, 2020.
You asked the Plan to reduce the coinsurance for the chemotherapy drugs. You say that you should only be
responsible for $250 for the chemotherapy treatment. You say you met your maximum out-of-pocket amount.
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 20%
coinsurance for chemotherapy drugs.
You have been asked to pay a total of $1,111.68 for the chemotherapy drugs. The chemotherapy drugs fall
within the "Medicare Part B prescription drugs" benefit category. See chart below.
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 coinsurance for the chemotherapy drugs provided from January 13, 2020
to January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 24, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foranticoagulant management provided on March 2, 2020.You asked the Plan to waive the copayment foranticoagulant management. You say that you disagree with the charges because you should not owe charges for 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 $40 copayment for services obtained by a specialist. You have been asked to pay the allowed amount of $11.40, which is less than the $40 copayment for anticoagulant management. Anticoagulant management 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 foranticoagulant management provided on March 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repair of your wheelchair and accessories.You asked the Plan to pre-approve repair of your wheelchair and accessories. You say that the repairs are necessary.The Plan denied your request. The Plan says the documentation provided does not indicate the wheelchair is needed for use inside of the home. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve repair of your wheelchair and accessories.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided from January 10, 2020 through January 12, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted to the hospital. You say that the copayment is waived if you are admitted. 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 $90 copayment for emergency services in an emergency room.
You have been asked to pay $80, which is less than the standard $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records do not support that you were admitted as an inpatient. 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 ER visit provided from January 10, 2020 through January 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve a second opinion. You say that you would like to get a second opinion from
this out-of-network provider. The Plan denied your request. The Plan says there are in-network providers
available to provide 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 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-approve
a second opinion to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the motion exercise device and sheepskin
pad provided on January 15, 2020.
You asked the Plan to waive the coinsurance for the motion exercise device and sheepskin pad. You say that
you didn't ask for these. You say that you were under the impression that the cost was covered by your policy.
The Plan denied your request. The Plan says the coinsurance 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 20%
coinsurance for Medicare-covered items.
You have been asked to pay $73.05 for the motion exercise device and sheepskin pad. 
The motion exercise device and sheepskin pad fall within the "Durable medical equipment (DME) and related
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 coinsurance for the motion exercise
device and sheepskin pad provided on January 15, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the cost for the recovery room and medical supplies for a colorectal cancer screening provided on December 30, 2019.You asked the Plan to waive the cost for the recovery room and medical supplies for a colorectal cancer screening. You say that this was incorrectly billed.The Plan denied your request. The Plan says that the cost share applied correctly.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 no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening. The Plan says you must pay $131.28 for the recovery room and 20% coinsurance for medical supplies for the colorectal cancer screening. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the recovery room and medical supplies for the colorectal cancer screening.The Evidence of Coverage does not clearly say that additional cost sharing applies to a recovery room and medical supplies for a colorectal cancer screening if performed in certain places of service. Therefore, we decided that the Plan has to waive the cost for the recovery room and medical supplies for a colorectal cancer screening provided on December 30, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 by a nonnetwork
provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider without 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 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 medical services provided on January 28, 2020
by a non-network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visits and ambulance transport provided from March 16, 2020 through April 17, 2020.
You asked the Plan to waive the copayment for the ER visits and ambulance transport. You say that you don't have the money to pay. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for Medicare-covered emergency care visits and a $100 copayment for in-network Medicare-covered ambulance services. ($100 copayment applies each way). You have been asked to pay a total of $580 for the ER visits and ambulance transport.
Date of Service
Service
Standard Copayment
Member Liability
March 16, 2020
ER Visit
$120
$120
March 24, 2020
ER Visit
$120
$120
April 13, 2020
ER Visit
$120
$120
April 17, 2020
ER Visit
$120
$120
April 17, 2020
Ambulance Transport
$100
$100
TOTAL:
$580
The ER visits fall within the "Emergency care" benefit category. The 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 the ER visits and ambulance transport provided from March 16, 2020 through April 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an Opt Out provider.
You asked the Plan to pre-approve dental services. You say that the services are necessary due to an accidental
fall. The Plan denied your request. The Plan says you do not have supplemental dental coverage and the
provider requested is an Opt Out provider. Therefore, coverage criteria has not been met.
The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given
by a physician or other practitioner who has opted out of Medicare.
We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare.
Based on this information, we decided that Medicare rules for coverage of dental services have not been met.
Therefore, we decided that the Plan does not have to pre-approve dental services to be provided by an Opt Out
provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung
Cancer Screening (G0297).
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the lung cancer screen is
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, an enrollee must have a
tobacco smoking history of at least 30 pack-years.
We looked at the file and Medicare rules. The record does not detail how long the enrollee as smoked for or
how many packs a day the enrollee smoked. Based on this information, we decided that Medicare rules for
coverage of the LDCT Lung Cancer Screening have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) purchased January 6, 2020 from an out of network provider.
You asked the Plan to pay for the hearing aids. You say that you are appealing since you followed the guidelines given to you when you called in on 12/05/19. You paid the provider in full and is seeking reimbursement. The Plan denied your request. The Plan says hearing aids must be purchased from an in-network hearing vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only purchased through an in-network provider. The health plan contract specifically says hearing aids ordered through providers other than the in-network vendor are not covered. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased January 6, 2020 from an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home ventilator, any type, used with non-invasive interface (E0466).
You asked the Plan to pre-approve the ventilator. You say that the enrollee currently has an authorization and has this device with another provider. You are simply just trying to switch her from their service to yours. The Plan denied your request. The Plan says the documentation provided does not support that the enrollee meets the criteria and there is no documentation that the enrollee could not be treated with another type of breathing treatment called positive airway pressure.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 pre-approve the ventilator. Our reviewer says that this enrollee does not meet the criteria for the requested device. Our physician reviewer found this enrollee has COPD requiring supplemental oxygen. However, there is no documentation of hypercarbia with increased pCO2 on arterial blood gas testing. Therefore, need for nocturnal respiratory support beyond oxygen has not been established. Further, Medicare does not cover a home ventilator when used as a BiPAP device. A home ventilator is not medically necessary and the coverage criteria for a home ventilator are not met 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve Home ventilator, any type, used with non-invasive interface (E0466).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine 10mg tablets.
You asked the Plan to pre-approve Cyclobenzaprine 10mg tablets. You say that the requested medication is
necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D
benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the
criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Cyclobenzaprine 10mg
tablets.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation provided from January 3, 2020 to January 31, 2020.
You asked the Plan to waive the copayments for cardiac rehabilitation. You say that you were not informed that you would owe a $50 copayment per each service and if you had known you would not have received the rehabilitation 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 $50 copayment for cardiac rehabilitation. You received cardiac rehabilitation from January 3, 2020 to January 31, 2020 for a total of 11 visits. Therefore, you are responsible to pay a $50 copayment per each visit. The total amount you owe is: $50 (copayment) x 11 (cardiac rehabilitation services) = $550. You have been asked to pay the total copayment amount of $550 for cardiac rehabilitation. Cardiac rehabilitation falls within the cardiac rehabilitation benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for cardiac rehabilitation provided from January 3, 2020 to January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) services provided February 14, 2020 to February 29, 2020.You asked the Plan to waive the copayment forthe SNF services. You say that you were told by the provider that the services would be covered at 100% and you would like the claim to be reprocessed and paid at 100%.The Plandenied your request. The Plan says this claim processed and paid correctly with the correct copayment applied per the plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 copayment per day, for days 1-20 and $178 copayment per day, for days 21-100 for skilled nursing facility (SNF) care. You have been asked to pay $1,344.28for the SNF services. The records show that days 1-20 of the SNF days were January 10, 2020 through January 30, 2020. Therefore, days February 14, 2020 through February 29, 2020 were all $178 per day. The SNF services fall within the skilled nursing facility (SNF) 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 forthe skilled nursing facility (SNF) services provided February 14, 2020 to February 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urography provided on February 13, 2020.
You asked the Plan to waive the copayment for the urography. You say that you were told there would be no charge for the service. You say you were also told there might be a $125 or $135 charge. 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 $125 copayment for each in-network Medicare-covered radiological diagnostic services, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $125 copayment for the urography.
You have been asked to pay an $83 copayment for the urography. The urography falls within the each "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the urography is not a standard x-ray.
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 urography provided on February 13, 2020.