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

We decided that the Plan does not have to pay for the physician services provided on August 9, 2019.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 August 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (73630) provided on January 17, 2019.
You asked the Plan to pay for the radiology services (73630). 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 radiology services (73630) provided on January 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on July 26, 2019.You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing aids are only payable when using a "in network provider".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 when you see a "in network provider".We looked at the file and the Plan's rules. "Out of network provider" is not a network hearing aid provider with the Plan. 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 doesnot have to reimburse you for hearing aids providedon July 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation, complete series of intraoral x-rays, 2 periodontal scalings and root planings, and 2 resin-based composites provided on August 9, 2019.You asked the Plan to pay forthe comprehensive oral evaluation, intraoral x-rays, scalings and planings, and resin-based composites. You say that when you signed up for the dental rider, you gave your credit card information to make the payment for the first month. You also say that you were not informed until August that you were behind on payments and the plan had terminated your coverage.The Plan denied your request. The Plan says you were no longer effective with the plan on this date of service. The Plan also says that the services rendered exceed the Plan's eligibility dates and are not covered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. The record shows that you were enrolled with the plan from April 01, 2019 through July 31, 2019 and then reinstated with the dental plan on September 1, 2019 through December 31, 2019.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation, complete series of intraoral x-rays, 2 periodontal scalings and rootplanings, and 2 resin-based composites provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents and oral hygiene instructions provided on August 6, 2019.

You asked the Plan to pay for the localized delivery of antimicrobial agents and oral hygiene instructions. You say that at your visit you were told that your insurance would cover the visit, including a fluoride treatment. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan says the Plan does not provide a benefit for these services.

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 localized delivery of antimicrobial agents and oral hygiene instructions provided on August 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge day management services (99239) provided by "the provider" June 25, 2019.You asked the Plan to pay forhospital discharge day management services. You say that your physician has provided medically necessary services in good faith and you request reconsideration for payment.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. "The beneficiary" was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forhospital discharge day management services (99239) provided by "the provider" June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physical therapy services provided on June 5, 2019 to June 26, 2019 by an out of network provider.You asked the Plan to pay forthe physical therapy 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.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe physical therapy services provided on June 5, 2019 to June 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical assistant services provided to the enrollee on May 1, 2019.You asked the Plan to pay forthe assistant services. You say that theservices were provided in the best interest of the enrollee.The Plan denied your request. The Plan says the claim was processed correctly according to the enrollee's 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $750 deductible. The enrollee has been asked to pay $72.39 for the assistant services. The records show that at the time the services were billed, the enrollee had not reached her $750 deductible. 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 pay forthe surgical assistant services provided on May 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroutpatient services provided from December 10, 2018 through April 15,2019.You asked the Plan to waive the coinsurance foroutpatient services. You say that your out-of-network copayment is extremely high. You say that the claims should be in-network.The Plan denied your request. The Plan says the out-of-network 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 50% coinsurance for out-of-network outpatient surgery.You have been asked to pay a total of $1,511.18 for outpatient services. Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityDecember 10, 2018Tendon Lengthening$650.9650%$325.48December 11, 2018Laser Destruction$1,303.5050%$651.75December 11, 2018Laser Destruction$329.1750%$164.59March 20, 2019Vein Injection $308.7750%$154.39March 20, 2019Ultrasound Guidance$60.5750%$30.29April 15, 2019Vein Injection $369.3450%$154.39April 15, 2019Ultrasound Guidance$60.5750%$30.29TOTAL:$1,511.18
The tendon lengthening, laser destruction and vein injectionsfall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The ultrasound guidance falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.The records show that the provider is out-of-network.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 foroutpatient services provided from December 10, 2018 through April 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the topical application of fluoride (D1208) provided on September 18, 2019.You asked the Plan to pay for the periapical x-rays, and the topical application of fluoride. You say that the services should be covered. You also say that the provider is in network with the Plan.The Plan denied your request. The Plan says the periapical x-rays are not listed as a covered service. The Plan also says that the topical application of fluoride 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 dental services you received are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay fo rthe initial periapical x-ray (D0220), the additional periapical x-ray (D0230), and the topical application of fluoride (D1208) provided on September 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy and endoscopy provided on August 1, 2019.You asked the Plan to waive the copayment forthe colonoscopy and endoscopy. You say that you were not advised of the cost. You say that you are on a fixed income and cannot afford the copayment.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 $250 copayment for each Medicare covered ambulatory surgical center visit or outpatient hospital facility visit.You have been asked to pay a $250 copayment for the colonoscopy and endoscopy. The colonoscopy and endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The colonoscopy and endoscopy are considered a surgical procedure. 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 colonoscopy and endoscopy provided on August 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on September 19, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that the doctor just walked in
and asked why you were there. You say that the doctor did not do anything. 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 $40
copayment for physician/practitioner services/network/specialist office visit.
You have been asked to pay a $40 copayment for a specialist office visit. Since a specialist was seen, the
correct copayment has been applied. A specialist office visit falls within the physician/practitioner
services/network/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 a
specialist office visit provided on September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 1, 2019.You asked the Plan to waive the copayment forlaboratory services. You say that you have never had a copayment for a blood draw. You say that the services should be paid for by the Plan.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 $30 copayment maximum for multiple lab and diagnostic tests at the same facility on the same day.You have been asked to pay a $29.62 copayment for laboratory services. Laboratory services 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 for laboratory services provided on July 1, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay fora chest x-ray (71045) provided on August 9, 2019.You asked the Plan to pay for the chest x-ray. You say that the service was provided and payment should be rendered.The Plan denied your request. The Plan says that the billed code is a duplicate claim line. Based on Medicare billing criteria, duplicate claims are not eligible for payment.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. The Plan did not provide evidence of payment of any duplicate claim for the services provided.Therefore, we decided that the Plan has to pay fora chest x-ray (71045) provided on August 9, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on October 7, 2019.You asked the Plan to waive the copayment for an ambulance trip. You say that you disagree with the charges because the hospital could not treat your condition.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 $225 copayment for ambulance services. You have been asked to pay a $225 copayment for an ambulance trip. 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 on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay from August 12, 2019 to August 17, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you say you paid the amount the hospital said was due upfront. You say you were not admitted as an inpatient until August 13, 2019. 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 $300 copayment per day for days 1-5 for Medicare-covered in-network inpatient hospital stays. You have been asked to pay a $300 copayment for each day the inpatient hospital stay. ($300 x 5 days = $1,500). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The medical record shows you were admitted as an inpatient on August 12, 2019.
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 inpatient hospital stay provided from August 12, 2019 to August 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided on May 30, 2019.You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that this was recommended for your age and other problems you were having. You say that the cost is unexpected.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 $350 per day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy, and outpatient surgery performed in an outpatient hospital or ambulatory surgical center.You have been asked to pay a $350 for the colonoscopy. The colonoscopy with biopsy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the colonoscopy was ordered for diagnostic purposes. 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 colonoscopy with biopsy provided on May 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance provided on May 8, 2019.You asked the Plan to pay for periodontal maintenance. You say that your dentist feels that this type of cleaning is best. You say that this falls under the annual preventive dental allowance.The Plan denied your request. The Plan says this is not a preventive dental 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 the preventive benefit.Therefore, we decided that the Plan does not have to pay for periodontal maintenance provided on May 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drugs received on August 14, 2019.You asked the Plan to pay forthe drugs. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.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 pay forself-administered drugs received on August 14, 2019.