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

We decided that the Plan does not have to waive the copayments for the emergency room visit and the
bronchoscopy provided on May 26, 2019 and May 28, 2019.
You asked the Plan to waive the copayments for the emergency room visit and the bronchoscopy. You say that
you have never received these types of bills before and you feel that insurance should cover them. 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 $110
copayment for each Medicare-covered emergency room visit and a $150 copayment per day for outpatient
procedures and services, including but not limited to, outpatient surgery performed in an outpatient hospital or
ambulatory surgical center.
You have been asked to pay a $110 copayment for the emergency room visit and a $150 copayment for the
bronchoscopy. The emergency room visit falls within the "Emergency care" benefit category. The
bronchoscopy falls within the "Outpatient hospital 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 copayments for the emergency room visit and the bronchoscopy provided on May 26, 2019 and
May 28, 2019.
Appeal type: Imaging
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for drugs, lab testing, EKG, CT scan, and EGD. You say that you
never had these services. The Plan says that the cost-sharing amounts you are being charged are correct.
We decided that the Plan has to waive the cost-sharing for drugs, lab testing, EKG, and CT scan.
The Plan follows Medicare rules. 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 rules say that the Plan must
make reasonable and diligent efforts to gather and forward information to the IRE regarding its decision to
deny payment or coverage. The rules say that the provider must furnish to the Plan sufficient information to
determine whether payment is due and the amount of payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to charge you these coinsurance amounts for drugs, an EKG, and a CT scan. The Plan says that you
must pay $28.00 coinsurance for drugs, $6.82 coinsurance for EKG, and $132.95 for CT scan. The Plan did not
provide information showing the allowed amounts of these services used to calculate these coinsurance
amounts. Without this information, we cannot determine whether the coinsurance amounts you are being
charged are correct. Therefore, the Plan has not shown that its decision to ask you to pay these coinsurance
amounts is correct or justified by the Plan contract.
The documentation submitted does not support that the laboratory testing you have been asked to pay a
copayment for was provided to you on these dates of service. You say that you did not received these services.
Without supporting documentation, the provider has not furnished sufficient information to determine that
payment is due for the billed laboratory testing. This provider is in-network with the Plan; therefore, you
should not be held liable for any amount for these charges that have not been supported.
Therefore, we decided that the Plan has to waive the cost-sharing for drugs, lab testing, EKG, and CT scan.
We also decided that the Plan does not have to waive the cost-sharing for an EGD.
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
copayment for outpatient surgery provided at a hospital. The record shows that an EGD was provided to you at
this hospital visit. You have been asked to pay $240.32, which is less than the $350 copayment for outpatient
surgery. Therefore, we decided that the Plan does not have to waive the cost-sharing for EGD.
Therefore, we decided that the Plan must reduce your total cost-sharing responsibility for this claim from
$418.09 to $240.32.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on January 4, 2020.You asked the Plan to pay forthe intraoral periapical x-rays. You say that all of these procedures are preventive and should be covered at 100% under your insurance policy.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 Plan only covers one set of bitewing x-rays. The first intraoral periapical x-ray and each additional intraoral periapical x-ray are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and two additional intraoral periapical x-rays provided on January 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 5, 2019.
You asked the Plan to pay for the physician's 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 physician's services. 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 on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 24, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 forthe medical services provided to the enrollee by an out-of-network provider on January 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on December 16, 2019. You asked the Plan to pay for the periodontal maintenance. You say that this was only a routine cleaning and exam which is covered by your network program. You also say that the provider billed the services incorrectly. The Plan denied your request. The Plan says this service is not a covered benefit. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, 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 periodontal maintenance provided on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea high strength lightweight manual wheelchair rental.You asked the Plan to pre-approvea high strength lightweight manual wheelchair rental. You say that you need the manual wheelchair.The Plan denied your request. The Plan says the information submitted does not show if the wheelchair will fit in your home orif you can safely move the wheelchair yourself.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 is no home assessment documentation. Based on this information, we decided that Medicare rules for coverage of a high strength lightweight manual wheelchair rental have not been met.Therefore, we decided that the Plan does not have to pre-approve a high strength lightweight manual wheelchair rental.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 15, 2019, and November 25, 2019.
You asked the Plan to pay for the services. You say that the plan provider was rude so you went to your previous provider. The Plan denied your request. The Plan says out-of-network services are not covered.
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 you by an out-of-network provider on November 15, 2019, and November 25, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the home health services provided from October 18, 2018 to October 20, 2018.
You asked the Plan to pay for the home health services. You say that this claim was billed correctly and should be paid. The Plan denied your request. The Plan says that value code 85 is not valid so this means that the claim is not payable.
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 states that this claim was correctly denied because the claim has an incorrect value code 85 reported. However, according to the Medicare rules for completing home health claims, value code 85 is used to report the Federal Information Processing Standards (FIPS) code for the state and county in which home health services were provided. Furthermore, no actual copy of the claim filed was submitted for review. Without a copy of the claim, we cannot verify whether the use of any value code was incorrect based on the Medicare rules. The Plan's denial rationale is not supported in this case. Therefore, we decided that the Plan has to pay for the home health services provided from October 18, 2018 to October 20, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-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 forthe medical services provided on October 30, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle (POV), group 2 standard (K0806).You asked the Plan to pre-approvea POV, group 2 standard. You say that the requested item is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that power mobility devices are covered when specific criteria is met.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 a POV, group 2 standard. Our reviewer says that the item is not medically necessary. Our physician reviewer found this device above lesser alternatives such as an ultra-lightweight chair or power mobility device (standard) is not necessary. A lesser device can address your needs. This request is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a POV, group 2 standard have not been met.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle (POV), group 2 standard (K0806).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a chest x-ray (71046) provided on January 2, 2020 by the treating physician.
You asked the Plan to waive the copayment for the chest x-ray. You say that you should not be responsible for the copayment since you were not advised of the high cost prior to the procedure. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $110 copayment for advanced imaging services performed at an outpatient hospital. You have been asked to pay $73.73 (the allowed amount) for the chest 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 a chest x-ray (71046) provided on January 2, 2020 by the treating physician.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on May 29, 2019 by a non-network provider.You asked the Plan to pay forthese 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 forthe laboratory services provided on May 29, 2019 by a non-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography (CT) scan rendered on December 25, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 forthe computed tomography (CT) scan rendered on December 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient consultation (99255) provided on December 21, 2019
You asked the Plan to pay for an inpatient consultation. You say that these services were authorized. The Plan denied your request. The Plan says these services were billed with an invalid code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99255 is not supported in the medical record. . Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient consultation (99255) provided on December 21, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient care provided from October 19, 2019 to October 23, 2019.
You asked the Plan to waive the copayment for inpatient care. You say that this should be paid. The Plan denied your request. The Plan says these services processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay $250 per day for days 1-7 of inpatient hospital care. The enrollee has been asked to pay $1000 for four days of inpatient care ($250 copayment x 4 days = $1000). 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 when he enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient care provided from October 19, 2019 to October 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for OT provided on November 4, 2019.You asked the Plan to waive the copayment for OT. You say that you disagree with the charges because you were there less than 15 minutes and feel that you did not receive OT 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 outpatient rehabilitation services. The medical records show that you received OT on November 4, 2019. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for OT. OT falls within the outpatient rehabilitation 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 forOT provided on November 4, 2019.
Appeal type: Lab
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 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service provided on June 17, 2019. You asked the Plan to waive the copayment for the second ambulance service. You say that you should not have to pay for two rides since the same ambulance company transferred you. The Plan denied your request. The Plan says you were charged this cost sharing 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 ambulance trip. You had two ambulance trips. The Plan charged you $500 for these services. 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 ambulance service provided on June 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional transport trips.You asked the Plan to pre-approvethe additional trips. You say that the transport services are necessary.The Plan denied your request. The Plan says your transport benefit was exhausted on March 19, 2020.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional transport trips.