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

We decided that the Plan does not have to waive the copayments for an X-ray (72270), a Computed
Tomography (CT) Scan (72126), and an injection (J2175) provided September 9, 2019.
You asked the Plan to waive the copayments for the X-ray, CT scan, and injection. You say that you should
only have to pay $150. The Plan denied your request. The Plan says there were separate copayments for each of
the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for CT Scans, a $30 Copayment for X-rays and a 20% Coinsurance for injected Part B drugs.
You have been asked to pay a $180.54 copayment for the CT scan, an X-ray and injected Part B drugs. 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 an X-ray (72270), a Computed Tomography (CT) Scan
(72126), and an injection (J2175) provided September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 12, 2019.
You asked the Plan to pay for the laboratory 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a Diagnostic Mammogram (77066) and Ultrasound (76641) provided January 14, 2020.
You asked the Plan to waive the copayments for the mammogram and ultrasound. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Basic Imaging services. You have been asked to pay a $45 copayment each for the mammogram and ultrasound, for a total of $90. The mammogram and ultrasound fall within the Basic Imaging 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 a Diagnostic Mammogram (77066) and Ultrasound (76641) provided January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0483) provided on November 25,
2019.
You asked the Plan to pay for the laboratory 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services (G0483) provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copay for the urgent care services you received on
December 12, 2019.
You asked the Plan to reduce the copay for the urgent care services. You say that your card says your copay is
$50. The Plan denied your request. The Plan says the copay was applied based on your 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 a $65
copay per visit to a medical facility or urgent care center.
You have been asked to pay a $65 copay for the urgent care services. The services fall within the urgently
needed 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 reduce the copay for the urgent care services you
received on December 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (93010 and 99291) provided on November 10, 2019.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this service because the diagnosis R65.20 billed is not valid as a primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that a code from subcategory R65.2 can never be assigned as a principal diagnosis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Specifically, the diagnosis R65.20 is not a valid primary diagnosis. Per the ICD-10, the underlying systemic infection should be assigned as principal diagnosis followed by the appropriate code from subcategory R65.2. Therefore, we decided that the Plan does not have to pay for emergency department services (93010 and 99291) provided on November 10, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Ambulance transports (A0425, A0426, A0428) provided December 13, 2019 and January 14, 2020.
You asked the Plan to waive the copayments for the ambulance transports. You say that the copayments should be waived as you wanted to transport the enrollee by car. The Plan denied your request. The Plan says the correct copayments were 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 $275 copayment for Ambulance Services. You have been asked to pay a $275 copayment for each ambulance transport. The ambulance transports fall 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 copayments for Ambulance transports (A0425, A0426, A0428) provided December 13, 2019 and January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient hospital services rendered on October 10, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is a financial hardship. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance per visit for outpatient surgery provided at a hospital outpatient facility and ambulatory surgical center.
Review of the file shows that you received outpatient hospital services on October 10, 2019. You have been asked to pay a 20% coinsurance for these services. These services fall within the outpatient surgery provided at a hospital outpatient facility and ambulatory surgical center 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 outpatient hospital services rendered on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services you or pay for the drugs you received on September 24, 2018.
You asked the Plan to waive the copayment and pay for the drugs. The Plan denied your request. The Plan says you are responsible for the cost share.
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 $360 copayment for outpatient surgery services. Review of the file shows that you received outpatient surgery services on September 24, 2018. You have been asked to pay a $360 copayment for the services. The services fall within the outpatient surgery 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. Additionally, the drugs you received on the date of service in question are not covered under your Part B plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgery services or pay for the drugs you received on September 24, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for shoulder surgery provided on December
16, 2019.
You asked the Plan to waive the coinsurance for outpatient surgery. You say that this charge is higher than you
expected. The Plan denied your request. The Plan says the coinsurance amount you are being charged is
correct.
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 outpatient surgery at an ambulatory surgical center. The allowed amount of the claim is
$12,299.54, resulting in a coinsurance obligation of $2,459.91.
You have been asked to pay 20% coinsurance for outpatient surgery. Outpatient surgery falls within the
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical
Centers 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 shoulder surgery provided
on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on January 9, 2020.
You asked the Plan to waive the copayment for an eye exam. 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 $40
copayment for eye exam to diagnose and treat diseases and conditions of the eye.
The medical records show that you received a diagnostic eye exam on January 9, 2020. Therefore, you are
responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for an eye exam. An eye exam falls within the vision care benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for an eye exam provided on January 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the bifocal lens (v2200) and the frames (v2020) purchased from the out of network (OON) provider on November 19, 2019.
You asked the Plan to issue reimbursement for the eyeglasses. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the eyeglasses were purchased from 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 issue reimbursement for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to issue reimbursement for these items. Therefore, we decided that the Plan does not have to issue reimbursement for the bifocal lens (v2200) and the frames (v2020) purchased from the out of network (OON) provider on November 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on December 4, 2019.
You asked the Plan to pay for the periodic oral evaluation. You say that you say that you had cleanings in May and November. You also say that you have nothing written down about an appointment on July 31 or another time in July. The Plan denied your request. The Plan says this procedure is limited to twice per calendar year.
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, oral examinations are limited to two per calendar year. The record shows that you received a periodic oral evaluation on May 22, 2019 and a problem focused limited oral evaluation on July 31, 2019 and your oral examinations benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home visit provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for rest home visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that 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 rest home visit provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional routine transportation trips.
You asked the Plan to pre-approve 2 additional routine transportation trips. You say that you need the additional routine transportation trips. The Plan denied your request. The Plan says the requested services exceed the benefit allowance. Therefore, coverage criteria has not been met.
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 10 one-way transportation 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-approve 2 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture provided on August 26, 2019.
You asked the Plan to pay for the maxillary partial denture. You say that you were told the denture would be covered. You also say that the provider should have told you it was not covered before you received the denture. The Plan denied your request. The Plan says this service is not listed as a covered dental 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 maxillary partial denture provided on August 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the Assisted Living Facility care (99337) provided on February 4, 2020.
You asked the Plan to pay for the assisted living facility care. You say that the services were medically necessary. The Plan denied your request. The Plan says services were not emergent or preauthorized. There were network providers available.
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 service 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 Assisted Living Facility care (99337) provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen supplies to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve oxygen supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested supplies can be provided by a network provider.
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 oxygen supplies to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four Testing (95999) provided September 25, 2019.
You asked the Plan to pay for the train of four testing. You say that services were medically necessary and properly billed. The Plan denied your request. The Plan says payment for these services was bundled in the primary procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95999 has a bundled relationship with code 95941 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Train of Four Testing (95999) provided September 25, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health services (99213, 90834) provided October 1 to October 8, 2019.
You asked the Plan to waive the copayment for the outpatient mental health services. You say that there should be no copayment. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Outpatient Mental Health Visits. You have been asked to pay a $40 copayment per visit for the outpatient mental health 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 outpatient mental health services (99213, 90834) provided October 1 to October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing tests provided on November 13, 2019 by an out-of-network provider.
You asked the Plan to pay for the hearing tests. You say that you went out-of-network because you wanted someone closer to your home and did not like the Plan provider you had in the past. 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. 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 hearing tests provided on November 13, 2019 by an out-of-network provider.