Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging and evaluation services provided to the enrollee from May 11, 2020 to August 31, 2020.

You asked the Plan to pay for these services. You say that these claims should be paid. The Plan denied your request. The Plan says these services are not related to manual manipulation of the spine and are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for imaging and evaluation services provided to the enrollee from May 11, 2020 to August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (CPT code D0140) provided on June 29, 2021.
You asked the Plan to pay for the dental services. You say that you cannot afford to pay for the service. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. The services is not listed in your EOC as a covered benefit; therefore, they are not covered. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (CPT code D0140) provided on June 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the surgical services provided on February 4, 2021, by an in-network provider.

You asked the Plan to waive the copayment for the surgical services. You say that when you signed up for the insurance you had not idea that you would have to pay $2000. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC 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). 

According to the Claims Report we received you are only being charged a $250 copayment for the surgery done on February 4, 2021. There was no mention of a cost incurred for medical supplies listed on the Claims Report. Therefore, you are asked to pay a $250 copayment for the surgery. 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 surgical services provided on February 4, 2021, by an in-network provider.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the radiation treatment provided on February 10, 2021.

You asked the Plan to pay for the radiation treatment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan denied payment for the claim stating the provider should have billed Original Medicare directly for consideration of payment. However, the Plan provided no supporting evidence in the case file proving that these services are not payable unless directly submitted to Original Medicare. Based on the lack of information provided by the Plan, we are unable to determine what the issue of non-coverage is. The Plan's denial reason is a blanket statement that the claim is not covered, but does not provide evidence as to why the claim is not covered. Therefore, we decided that the Plan has to pay for the radiation treatment provided on February 10, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148) provided to the enrollee on August 12, 2020.
You asked the Plan to pay for the MRI. You say that please process this claim for payment as we billed the claim to the wrong Payer ID Number for 2020 claims. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the MRI was not filed until March 1, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148) provided to the enrollee on August 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for telehealth physician services provided by on June 8, 2021.

You asked the Plan to waive the copayment for telehealth physician services. You say that you were never informed there would be copays for a telehealth visit. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for telehealth physician services. 

We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $15 copayment for telehealth physician services. The Plan contract does not clearly say how much enrollees must pay for telehealth physician services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for telehealth physician services provided on June 8, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayments for the skin surgery you had on June 1, 2021, and the procedure to place a skin graft substitute you had on June 10, 2021.

You asked the Plan to waive the copayments for the dermatology procedures. You say that these services should not be considered surgery. The Plan denied your request. The Plan says that it initially charged you coinsurance for these services incorrectly. The Plan says that these services are surgical services, so the outpatient surgery copayment of $225 has been applied to each date of service.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $225 copayment for outpatient surgery in an ambulatory surgery center or an outpatient hospital facility. 

The Plan says you must pay a $225 copayment for the dermatology procedures. We do not find the Plan's argument persuasive. While we agree that Medicare considers the procedure codes you were billed to be surgical codes, we find that the Plan's application of the outpatient surgery copayment is flawed in this case. According to your Evidence of Coverage, the outpatient surgery copayment applies to services rendered in an ambulatory surgery center or an outpatient hospital facility. The limited case file documentation that the Plan submitted to us does not show that these services occurred at either an ambulatory surgery center or outpatient hospital facility. The Plan failed to provide us with the claims for these services or the corrected Explanations of Benefits that may have included this information. Without evidence that these services took place at one of these location types, we cannot confirm that the Plan's application of this cost sharing is correct. In addition, since the Plan failed to provide us copies of their corrected Explanations of Benefits (as they noted that they reprocessed your claims), we are unable to tell if the Plan did so correctly. Without these pieces of information, we find that the Plan has not supported their decision to charge these copayments. Therefore, we decided that the Plan has to waive the copayments for the skin surgery you had on June 1, 2021, and the procedure to place a skin graft substitute you had on June 10, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost sharing for the knee arthroplasty surgery you had on May 19, 2021-May 20, 2021, and the physical therapy (PT) evaluation you had on May 20, 2021.
You asked the Plan to reduce the cost sharing for the knee surgery and the PT evaluation. You say that this should have been considered an inpatient admission because you spent the night in the hospital. You stated that if this had been billed as inpatient, you would only have a $390 copayment and you wouldn't have to pay anything extra for the PT evaluation. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $550 copayment for outpatient surgery in an outpatient hospital facility and a $40 copayment for outpatient rehabilitation evaluations. You have been asked to pay a $550 copayment for the knee surgery and a $40 copayment for the PT evaluation. The medical records show that you were not admitted as an inpatient to the hospital for this procedure, so you are considered an outpatient. This means that you have been asked to pay the correct amounts 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 knee arthroplasty surgery you had on May 19, 2021-May 20, 2021, and the physical therapy (PT) evaluation you had on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from January 26, 2021 to February 4, 2021.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you 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 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 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 from January 26, 2021 to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis services provided from May 5, 2021, through May 31, 2021.
You asked the Plan to waive the coinsurance for dialysis services. You say that you were told you would not have to pay anything for these services. You say that you cannot afford the cost. 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 20% coinsurance for dialysis services. You have been asked to pay $65.52 for each visit, which is 20% of the allowed amount for dialysis services ($327.60 allowed amount x 20% coinsurance = $65.52). Dialysis services falls within the Services to Treat Kidney Disease 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 dialysis services provided from May 5, 2021, through May 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for lab services you received on July 3, 2021, and July 6, 2021.
You asked the Plan to waive the copayments for the lab services. You say that you had a poor experience at the lab on July 3, 2021 and you do not believe you should have to pay these copayments. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan says that for the lab services rendered on July 6, 2021, the allowed amount for these labs ($5.69) is less than your copayment obligation, so you are responsible for the full allowed amount for those services.
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. You have been asked to pay a $10 copayment for the lab services. These copayments apply regardless of your satisfaction with the services 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 copayments for lab services you received on July 3, 2021, and July 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from June 4, 2021, to July 1, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you are on a fixed income and cannot afford this cost sharing. 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 $0 copayment for days 1-20, and a $160 copayment per day for days 21-44 for skilled nursing facility services.

Records show that you were in the SNF for a total of 27 days. You were not charged a copayment for the first 20 days in accordance with your Evidence of Coverage. For the remaining 7 days, you have been asked to pay a $160 copayment per day, for a total of $1,120. 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 you received from June 4, 2021, to July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a walking boot provided on April 21, 2021.
You asked the Plan to waive the coinsurance for a walking boot. You say that the cost sharing should be waived because you did not use the equipment. You say it was uncomfortable and not beneficial to 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 10% coinsurance for durable medical equipment. You have been asked to pay $32.55, which is 10% of the allowed amount for a walking boot ($325.53 allowed amount x 10% coinsurance = $32.55). A walking boot falls within the Durable Medical Equipment (DME) and Related 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 a walking boot provided on April 21, 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) and prophylaxis - adult (D1110) provided by an out-of-network (OON) provider on April 8, 2021.
You asked the Plan to pay for the periodic oral exam and dental cleaning. You say that you would like the services covered The Plan denied your request. The Plan says dental services are not covered when provided out-of-network.
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 contract says that when received out-of-network, you are responsible for 100% of the cost of periodic oral exams and dental cleanings.
We looked at the file and Medicare rules. In this case the services at issue were rendered by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided by an out-of-network (OON) provider on April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided on January 5, 2021, to January 15, 2021.

You asked the Plan to pay for inpatient mental health care. You say that you are requesting authorization for inpatient psychiatric care as the enrollee was seen based on medical necessity. The Plan denied your request. The Plan says the enrollee's identity cannot be confirmed with the clinical information provided.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of these services have not been met. Specifically, the identity of the enrollee could not be verified in
this case. Without this information, we cannot determine if services were rendered and if they were done for
the enrollee at issue. Therefore, we decided that the Plan does not have to pay for inpatient mental health care
provided on January 5, 2021, to January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 6, 2020.
You asked the Plan to pay for services from this provider. You say that in your appeal to the Plan and in a letter sent directly to this office that your appeals are not being read and/or understood and you believe the Plan is required to cover these services. The Plan denied your request. The Plan says the Medicare data base shows this provided opted out of Medicare on July 1, 2016.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician services provided on February 6, 2020.
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 April 26, 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.

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 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 April 26, 2021.