Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from August 25, 2021, to September 2, 2021.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you assumed all coronavirus (COVID-19) claims would be paid in full without a copayment. The Plan denied your request. The Plan says waivers for all COVID-19 claims were effective until June 1, 2020. Therefore, the proper copayment was applied for this service.   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 per day for Days 1-7 and a $1,575 out-of-pocket limit every benefit period. From August 25, 2021, to September 2, 2021, there was a total of 9 days in the inpatient hospital. With a $225 copayment charged daily for the first 7 days. The total amount for the 7 days in the inpatient hospital was $1,575 ($225 daily copayment x 7 days) which is also the maximum amount for this benefit period.  You have been asked to pay a $1,575 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the Inpatient hospital care benefit period 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 inpatient hospital stay from August 25, 2021, to September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a specialist office visit (99213) provided on September 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit. You say that the Plan told you that you needed a referral letter from the enrollee's primary physician because you are out of network, and you did not have a primary physician on file for the enrollee. You also say that the primary physician that the Plan gave you discharged the enrollee from her practice in August of 2020. The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that they have also determined that these services are not urgent, emergent, nor were they 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 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 a specialist office visit (99213) provided on September 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Eylea injection you received on October 13, 2021.  You asked the Plan to waive the coinsurance for the Eylea injection. You say that the last time you had this injection it only cost you $42.  You said that the doctor didn't tell you how much this would cost. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs.   You have been asked to pay 20% coinsurance for the Eylea injection. The Eylea injection falls within the Medicare Part B drugs benefit category. This cost sharing applies regardless of what you may have paid in the past. 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 Eylea injection you received on October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on August 17, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as you were not asked for a copayment at the time of service and it is a follow-up visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based on 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 $35 copayment for Physician/Practitioner services, including doctor's office visits.   You have been asked to pay a $35 copayment for a specialist office visit. Based on your contract with the plan, specialist visits are not considered follow-up visits after 90 days from the original procedure date, therefore these services are ineligible to be considered a follow-up. Specialist office visits fall within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist office visit (99213) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140), and general anesthesia (D9223) provided by a participating provider on September 15, 2021.  You asked the Plan to pay for a limited oral evaluation and general anesthesia. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the benefit limit for D0140 has already been exhausted.  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 covers one limited oral evaluation every calendar year.   We looked at the file and Medicare rules. The Plan has overturned the decision for D9223. There has been a 50% coinsurance applied to general anesthesia.    Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), and general anesthesia (D9223) provided by a participating provider on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the specialist office visit, endovenous ablation therapy, and vein injection procedures provided by a network provider from March 12, 2021, to April 20, 2021.  You asked the Plan to waive the copayments for the specialist office visit, the ablation therapy, and the vein injection procedures. You say that you were not informed of any copayment due in or out the office service. You say you cannot afford the bills. The Plan denied your request. The Plan says you have been asked to pay 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 $20 copayment for each in-network Medicare-covered specialist visit.   You have been asked to pay a $20 copayment for the specialist office visit, a $20 copayment for the ablation therapy, and a $20 copayment the vein injection procedures on each date of service. The specialist office visit, the ablation therapy, and the vein injection procedures fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visit, endovenous ablation therapy, and vein injection procedures provided by a network provider from March 12, 2021, to April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an unspecified preventative procedure (D1999) provided by a participating provider on November 15, 2021.  You asked the Plan to pay for an unspecified preventative procedure. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the dental work that was provided 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 an unspecified preventative procedure (D1999) provided by a participating provider on November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 8.  You asked the Plan to pre-approve the dental service. You say that you need this service. The Plan denied your request. The Plan says the root canal is not medically necessary.  Medicare generally does not cover dental services. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, there was no clinical documentation submitted to justify the need for this service. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 8.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 21, 2021.  You asked the Plan to pay for the dental service. You say that your previous dentist retired. You say that you needed to find a new one. You also say that an exception should be made. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.  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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 16, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the urgent care visit provided by a network facility on September 28, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be responsible for the copayment because they did nothing for you. The Plan denied your request. The Plan says you have been asked to pay 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 $65 copayment for each urgent care visit.   You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The medical record shows services were rendered.  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 urgent care visit provided by a network facility on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for shock wave therapy provided on July 23, 2020, to August 24, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the shock wave therapy. You say that you are appealing the claim. 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for shock wave therapy provided on July 23, 2020, to August 24, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2021.  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 regard 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 October 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve epidural injections.  You asked the Plan to pre-approve epidural injections. You say that you are in a lot of pain and needs these injections. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because there is not imaging showing that you have a condition for which these epidurals are covered.  The Plan follows Medicare rules. Medicare rules state that epidural injections may be covered if certain criteria are 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 epidural injections. Our reviewer says that you do not meet the Medicare criteria for the requested epidural injections. Our physician reviewer found your request exceeds the utilization criteria and your imaging results do not support this procedure. You have not had a surgical consultation. This request is not medically reasonable and necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural injections.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for Part B injectable drugs and medical supplies used during a comprehensive electrophysiologic evaluation with 3D mapping performed on February 19, 2021.  You asked the Plan to waive the coinsurance for the Part B drugs, supplies, and cardiology test. You say that you were informed that the copayment would only be $350 and the procedure did not work. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Part B drugs, including injectable drugs.  Your contract with the Plan also clearly says that you must pay a 20% coinsurance for diagnostic tests and procedures as well as surgical or medical supplies.  Drug/Procedure/Item Allowed Amount 20% Coinsurance Drug Administration (0250) $7.32 $1.46 Surgical Supplies (0272) $9,375.00 $1,875.00  $1,551.20 $310.24  $8,112.46 $1,622.49  $1,865.47 $373.09  $631.62 $126.32  $1,005.49 $201.10  $112.55 $22.51 Closure Device (0278) $1,551.20 $310.24 Cardiology Procedure (0480) $5,135.87 $1,027.17  $5,135.87 $1,027.17 Part B Drugs (0636) $38.79 $7.76  $5.85 $1.17  $3.01 $0.60  $2.32 $0.46  $0.99 $0.20  $3.71 $0.74  $3.45 $0.69  $14.63 $2.93  $0.92 $0.18 Total:  $6,911.52  You have been asked to pay $6,911.52, which is 20% of the allowed amount for the Part B drugs, supplies, and cardiology test. The Part B drugs fall within the Medicare Part B Prescription Drugs benefit category. The cardiology test and supplies 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 coinsurance for Part B injectable drugs and medical supplies used during a comprehensive electrophysiologic evaluation with 3D mapping performed on February 19, 2021.   Your complaint about the Plan customer service representative informing you of the $350 copayment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 29, 2021.  You asked the Plan to pay for home health services. You say that this service was medically necessary. The Plan denied your request. The Plan says the claim was filed without a valid type of bill.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, a valid 4-digit Type of Bill was not included on the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a nasal endoscopy provided on August 3, 2021.  You asked the Plan to waive the copayment for the nasal endoscopy. You say that the provider did not inform you of any charges. 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 $150 copayment for surgery or other services provided to you at an outpatient hospital.    You have been asked to pay a $150 copayment for the nasal endoscopy. The nasal endoscopy 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 copayment for a nasal endoscopy provided on August 3, 2021.