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

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of 
the spine you you had June 16, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you do not agree with this copayment. 
The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that 
because the allowed amount for this service ($196.00) is less than your copayment obligation, you are 
responsible for the full allowed 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 diagnostic radiology services.  
 
You have been asked to pay a $225 copayment for the MRI. The MRI falls within the diagnostic radiology 
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 magnetic resonance 
imaging (MRI) of the spine you you had June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110) and bitewings - four radiographic images (D0274) provided July 28, 2021.
You asked the Plan to pay for the periodic oral exam, dental cleaning and bitewing x-rays. You say that you were unaware that the provider is now out-of-network. The Plan denied your request. The Plan says the services were provided out-of-network and are not covered. dicare 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. The Plan covers the periodic oral exam, dental cleaning and bitewing x-rays when the services are provided by a provider in the Plan's network. We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, dental cleaning and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110) and bitewings - four radiographic images (D0274) provided July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic angiography (CTA) of the abdominal aorta you had on June 23, 2021.
You asked the Plan to waive the copayment for the CTA. You say that you were told that there wouldn't be a copayment because this test was ordered by your doctor. The Plan denied your request. The Plan says you were charged this copayment 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 diagnostic radiology services. You have been asked to pay a $250 copayment for the CTA. The CTA falls within the diagnostic radiology services benefit category. This copayment applies even if the test is ordered by your doctor. 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 computed tomographic angiography (CTA) of the abdominal aorta you had on June 23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services rendered on April 21, 2021.
You asked the Plan to waive the copayment for emergency room services. You say that you were not able to be seen or put into a room when you went to the emergency room. You also say you were in an axillary waiting room and was seen, so you feel as though they are overcharging the insurance company for your visit. You also say that you should not be responsible for this visit. The Plan denied your request. The Plan says you were 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 $90 copayment for per visit for Medicare-covered emergency room visits. You have been asked to pay a $90 copayment for emergency room services. Although you did not receive emergency care in a room, the record shows emergency care was received. 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 emergency room services rendered on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 6, 2021.
You asked the Plan to pay for code 99153. 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 providers must report services correctly. We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant at surgery services provided on April 21, 2021.
You asked the Plan to pay for the assistant at surgery 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 follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant at surgery services provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the functional electric stimulator provided on May 26, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the functional electrical stimulator. You say that you had no idea that you had to 
use a contracting supplier with the Plan.  You stated that you cannot afford this device.  You also stated that 
this out-of-network supplier is the only one that has this device. The Plan denied your request. The Plan says 
durable medical equipment you received from out-of-network providers without a referral is 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 provider in this case is not a network provider with the Plan. There is no evidence that you had a referral 
from your primary care provider or the Plan to use this out-of-network provider. 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 functional electric stimulator provided on May 26, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 1, 2021, to July 3, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford 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 $350 copayment for days 1-5 for inpatient hospital care. 

You received inpatient hospital care from July 1, 2021, to July 3, 2021. Therefore, you are responsible to pay a $350 copayment for days 1-2 (July 1, 2021, to July 2, 2021). The total amount you owe is: $700.

You have been asked to pay the total copayment amount of $700 for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital 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 inpatient hospital care provided from July 1, 2021, to July 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic angiography (CTA) you had on June 2, 2021.
You asked the Plan to waive the copayment for the CTA. You say that you were not told about this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $150 copayment for advanced radiology services.
You have been asked to pay a $150 copayment for the CTA. The CTA falls within the advanced radiology 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 computed tomographic angiography (CTA) you had on June 2, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services rendered on July 29, 2021.
You asked the Plan to waive the copayment for emergency room services. You say that you were never seen by a doctor and you laid in bed for 2.5 hours. You also say you informed the hospital you did not want or need an x-ray; you only went in for a tetanus shot, and then you walked out of the facility. The Plan denied your request. The Plan says you were 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 $100 copayment for Medicare-covered emergency room visits. You have been asked to pay a $100 copayment for emergency room services. Although you left before seeing the physician, you did receive emergency room services. There is no provision within the contract which would waive the copayment if you leave before a full evaluation by the physician. 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 emergency room services rendered on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on July 2, 2021.
You asked the Plan to pay for the domiciliary visit. You say that it is the nursing facility's responsibility to get authorizations for their patients. 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 had network providers available who could have provided 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 domiciliary visit provided on July 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on May 27, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you would like your three health plans to coordinate benefits so you will not owe any money. 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 $100 copayment for each one-way ambulance trip.
You have been asked to pay a $100 copayment for the ambulance transport. 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 ambulance transport provided on May 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for podiatry services you received on
April 20, 2021, and May 11, 2021.
You asked the Plan to waive the copayments for the podiatry services. You say that the podiatrist misdiagnosed you and the doctor did nothing on your second visit. The Plan denied your request. The Plan says you were charged these copayments 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 for podiatry visits.
You have been asked to pay a $30 copayment for the podiatry services. These copayments apply regardless of your satisfaction with the visits. 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 podiatry services you received on April 20, 2021, and May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on June 2, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. The Plan 
denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue.  
 
We found no exception that would require the Plan to pay for these items/services. The records provided for 
review do not show that the service at issue was urgent or emergent. 
 
Therefore, we decided that the Plan does not have to pay for the laboratory work provided on June 2, 2021, by 
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Part B drugs provided on May 12, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that you have never been charged for 
this service before. The Plan denied your request. The Plan says the coinsurance applied was 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 a 20% 
coinsurance for in-network chemotherapy drugs.  

The allowed amount of this claim is $1,762.89. You have been asked to pay $352.58 for Part B drugs 
($1,762.89 x 20% = $352.58). Part B drugs fall within the Medicare Part B Prescription Drugs 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 Part B drugs provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for acupuncture.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are available in-plan.
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 an out-of-network referral for acupuncture
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the outpatient surgery you had on June 14, 2021, the physical therapy services you received on June 14, 2021, and the occupational therapy services you received on June 15, 2021.
You asked the Plan to reduce the cost sharing for the outpatient surgery, the physical therapy services, and the occupational therapy services. You say that when you had shoulder surgery in 2020, you paid significantly less. You feel as though these charges are too high. 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 25% coinsurance, up to $1200 for outpatient surgery in a hospital and a $35 for each visit for therapy services. You have been asked to pay 25% coinsurance for the outpatient surgery, and a $35 copayment each for the physical therapy services and the occupational therapy services. The allowed amount for the surgery you had is $11032.79. According to your contract, you are responsible for 25% coinsurance, which would equal $2758.20. However, this cost sharing is capped at $1200, so that is what you are being charged for this service. 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 cost sharing for the outpatient surgery you had on June 14, 2021, the physical therapy services you received on June 14, 2021, and the occupational therapy services you received on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup procedure (D2950) provided on June 30, 2021.
You asked the Plan to pay for a core buildup. You say that the procedure at issue was a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met because you have already received the maximum coverage allowed for dental 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. The Plan pays up to $1,000 every year for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services combined. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a core buildup have not been met. Specifically, the Plan has documented that the $1,000 dental
allowance has been exhausted for 2021. Therefore, we decided that the Plan does not have to pay for a core buildup procedure (D2950) provided on June 30, 2021.