Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on September 2, 2021.

You asked the Plan to waive the copayment for outpatient mental health care. You say that you are being charged $30 but you saw a physician's assistant so you should not be responsible for 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 $30 copayment for each individual therapy session and a $15 copayment for each group therapy session for outpatient mental health care. 

The record shows that you received an individual therapy session on September 2, 2021. Therefore, you are responsible to pay the $30 copayment.

You have been asked to pay a $30 copayment for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health 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 outpatient mental health care provided on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on November 6, 2020.  You asked the Plan to pay for the complete series of intraoral x-rays. You say that you received this service with the understanding and reassurance from the provider that there would be a zero-dollar copay with no additional out of pocket cost. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.  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, complete series of intraoral x-rays (D0210) is limited to one procedure every three plan years. The record shows that you received a complete series of intraoral x-rays (D0210) on September 30, 2020 and your complete series of intraoral x-rays (D0210) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on November 6, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services provided from August 17, 2021, to August 29, 2021.  You asked the Plan to waive the copayment for the SNF services. You say that you feel that this bill is wrong since you were already in a rehab facility earlier and were not charged. 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 $0 per day for days 1-20 and $184 per day for days 21-100 for each skilled nursing facility (SNF) benefit period. A benefit period ends when you have gone 60 days without being admitted to the hospital of a skilled nursing facility.   The file shows that you were in a rehabilitation facility from June 30, 2021, to July 12, 2021. This stay began the first 12 days for the benefit period. You were then admitted to the skilled nursing facility from August 17, 2021, to August 29, 2021. Since 60 days had not passed, this stay is considered part of the same benefit period and includes days 13-24 for the benefit period. Therefore, you have been asked to pay $184 per day for days 21-24 of SNF services. The total for the stay is $736 ($184 copayment x 4 days = $736). The SNF services fall within the Skilled Nursing Facility (SNF) 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 skilled nursing facility (SNF) services provided from August 17, 2021, to August 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two gingival irrigations (D4921 x2) provided on October 11, 2021.  You asked the Plan to pay for the gingival irrigations. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you were advised by the provider on this date of service that the gingival irrigations would not be covered.  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 two gingival irrigations (D4921 x2) provided on October 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the scaling and root planing (D4342 x 4), gingival irrigation (D4921 x 4), take home drugs (D9630 x 2) provided on August 23, 2021.  You asked the Plan to pay for the dental services. You say that you received an estimate from the provider for $283.80. You say that you received a bill for $534.40. You say that the provider advised they would resubmit the claim. You also say that you should not be responsible for this bill. The Plan denied your request. The Plan says the scaling and root planing, gingival irrigation, and take home drugs are not listed as covered services.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling and root planing, gingival irrigation, and take home drugs are not among those covered under this benefit. Additionally, the record shows that you signed an agreement advising the estimate is not final member responsibility is dependent on insurance payments and member plan benefits. The member liability amount may be different than the estimated amount. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4342 x 4), gingival irrigation (D4921 x 4), take home drugs (D9630 x 2) provided on August 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on October 20, 2021. 

 You asked the Plan to pay for the comprehensive exam. You say that your old provider would not fix your teeth, and the new provider required this exam before continuing treatment. The Plan denied your request. The Plan says you previously had this type of exam in February 2020, and it was covered by the Plan at that time. This service may only be covered once every three years. It has not been three years since you last had a comprehensive exam.  

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 comprehensive oral exam (D0150) provided on October 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided on February 8, 2021.  

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for lab services you received on October 5, 2021.  

You asked the Plan to waive the copayment for the lab services. You say that there should be no copayment for this because these labs were part of your annual physical. 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 $10 copayment for lab services.   

Your contract says that the annual physical includes the following services: detailed medical/family history and performance of a head-to-toe hands on assessment and exam of all body systems, a health risk assessment and a discussion of potential gaps in care.  It does not include lab services or diagnostic testing. You have been asked to pay a $10 copayment for the lab 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 lab services you received on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the provision of test materials provided from May 10, 2021, to September 9, 2021.  You asked the Plan to waive the copayments for the provision of test materials. You say that you disagree with how the claims are being processed and you never owed a copayment in the past. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]  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 specialist services.  You received the provision of test materials from May 10, 2021, to September 9, 2021, for a total of 4 services. The provision of test materials is considered a physician service. Therefore, you are responsible to pay a $45 copayment per each visit. The total amount you owe is: $180.    You have been asked to pay the total copayment amount of $180 for the provision of test materials. The provision of test materials 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 provision of test materials provided from May 10, 2021, to September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) and the laboratory service (88307) rendered by the out-of-network (OON) provider on August 2, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 office visit (99204) and the laboratory service (88307) rendered by the out-of-network (OON) provider on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on October 28, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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. 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 out of network physician services provided to the enrollee on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
October 28, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. You say that you thought you had more coverage for the eyeglasses. The Plan denied your request. The Plan says the claim processed correctly. The Health Plan made payment of $200 toward the eyeglasses and the remaining $358 is the member responsibility.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the claim processed correctly. The Plan has paid the maximum eyewear benefit amount of $200, and you are responsible for the remaining amount of $358. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and home health aide (HHA) or certified nurse assistant (CNA) services (S9122) provided from June 23, 2021, to August 28, 2021.  You asked the Plan to pay for the ground mileage and HHA or CNA services. You say that the services rendered, and currently being rendered, were ordered based on recommendations for ongoing medical treatments and surgery. You also say that the original facility you were treated by is understaffed and unable to provide the care you needed. The Plan denied your request. The Plan says these services were rendered by a provider who is not under contract with the health plan and is not certified for Medicare.  The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ground mileage and HHA or CNA services have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and home health aide (HHA) or certified nurse assistant (CNA) services (S9122) provided from June 23, 2021, to August 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Gel-One injection.  You asked the Plan to pre-approve the injection. You say that you don't want to have knee surgery. The Plan denied your request. The Plan says this will be provided by a specialty pharmacy and not the provider's office.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for office visits provided on March 1, 2021, and October 11, 2021.  You asked the Plan to waive the coinsurance for the office visits. You say that the services should be covered. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Physician/Practitioner Services, Including Doctor's Office Visits.     You have been asked to pay a 20% coinsurance for two office visits. (Total allowed is $217.07 x 20% = $43.4).  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 office visits provided on March 1, 2021, and October 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from IRF care to optimize her level of functioning prior to returning home. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited (problem-focused) oral exam (D0140) provided on October 8, 2021.  You asked the Plan to pay for the limited exam. You say that this service was medically necessary. The Plan denied your request. The Plan says this service may be covered once per plan year, and the Plan previously issued payment for a limited oral exam provided on June 15, 2021. The exam provided on the date in question exceeds the frequency limitations of your 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. The Plan can cover one limited exam to evaluate a problem (D0140) per plan year. Though the Plan offers a dental benefit in excess of Medicare coverage, the limited exam is requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you had a previous limited exam in 2021 which was covered by the Plan. Therefore, we decided that the Plan does not have to pay for the limited (problem-focused) oral exam (D0140) provided on October 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a shoulder injection provided on August 4, 2021.

You asked the Plan to waive the copayment for the injection. You say that you feel that the charge is excessive for a doctor's office visit. 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 $325 copayment for surgery or other services provided at an outpatient hospital. 

You have been asked to pay $286.16, which is less than the $325 copayment for the injection. The injection is considered a surgical procedure and 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 shoulder injection provided on August 4, 2021.