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

We decided that the Plan does not have to waive the coinsurance for wound debridement services you received at an outpatient hospital clinic from August 3, 2021, to August 17, 2021.
You asked the Plan to waive the coinsurance for the wound debridement services. You say that you were never told that you would have to pay an additional amount for the facility in addition to your specialist copayment. The Plan denied your request. The Plan says it has reprocessed the claim and it is not charging you the specialist copayment for these visits. However, the Plan says that the outpatient hospital coinsurance was charged 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 outpatient hospital services.
You have been asked to pay 20% coinsurance for the wound debridement services. The wound debridement services fall within the outpatient hospital 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 coinsurance for wound debridement services you received at an outpatient hospital clinic from August 3, 2021, to August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the cervical spine (72126), and a myelography lumbar injection (62302) rendered on July 6, 2021.
You asked the Plan to waive the copayment for a computed tomography scan of the cervical spine and a myelography lumbar injection. You say that 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 $275 copayment per day, per provider, per Medicare-covered diagnostic radiology services. Your contract with the Plan also clearly says that you must pay a $325 copayment for each Medicare-covered outpatient hospital facility visit. You have been asked to pay a $275 copayment for a Computed tomography scan of the cervical spine. Computed tomography scans of the cervical spine fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a $325 copayment for a myelography lumbar injection. Myelography lumbar injections fall under the Outpatient Hospital 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 a computed tomography (CT) scan of the cervical spine (72126), and a myelography lumbar injection (62302) rendered on July 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ultrasound-guided needle placement and the ultrasound of the veins you received on March 29, 2021.
You asked the Plan to waive the copayment for the ultrasounds. You say that you were told you would have a $45 copayment and you were not told it would be $125. 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 $125 copayment for diagnostic radiological services performed in a physician's office. You have been asked to pay a $125 copayment for the ultrasounds. The ultrasounds fall within the diagnostic radiological services performed in a physician's office 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 ultrasound-guided needle placement and the ultrasound of the veins you received on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on August 4, 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 medical services provided to the enrollee on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an urgent care specialist on July 7, 2021.
You asked the Plan to waive the copayment for the specialist visit. You say that you were not signed up for the Plan with your consent, so you are disputing the copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you have been disenrolled effective July 31, 2021.
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 specialist visits. You have been asked to pay a $35 copayment for the specialist visit. 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 office visit you had with an urgent care specialist on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assisted living facility visit provided on May 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON assisted living facility visit. You say that the provider relies on the assisted living facility to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. It is the provider's obligation to confirm the patient's insurance coverage prior to rendering services. 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 assisted living facility visit provided on May 25, 2021, by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the urinary tract infection panel testing provided on  July 21, 2021.  You asked the Plan to pay for the testing services. You say that the testing reduces the use of inappropriate medication and hospitalization. The Plan denied your request. The Plan says the testing is unproven.  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.  We looked at the file and the rules. In this case, there were insufficient medical records to show the testing was ordered due to signs and symptoms of the enrollee. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the urinary tract infection panel testing provided on July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound you had at an outpatient hospital facility on July 21, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that this test should be covered in full. 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 $95 copayment for basic radiological services at an outpatient hospital. You have been asked to pay a $95 copayment for the ultrasound. The ultrasound falls within the basic radiological services at an outpatient hospital 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 retroperitoneal ultrasound you had at an outpatient hospital facility on July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy procedure you had at an outpatient hospital facility on June 3, 2021.
You asked the Plan to waive the copayment for the endoscopy procedure. You say that this was a routine endoscopy, so you thought this was covered at 100% 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 $325 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $325 copayment for the endoscopy procedure. The endoscopy procedure falls within the outpatient surgery at an outpatient hospital facility benefit category. Nowhere in your contract does
it say that endoscopies (other than screening colonoscopies) are covered at 100%. 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 esophagogastroduodenoscopy procedure you had at an outpatient hospital facility on June 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient psychiatric facility services provided from May 17, 2021, to June 1, 2021.  You asked the Plan to waive the copayment for the inpatient psychiatric facility services. You say that these services should be covered because they were medically necessary. The Plan denied your request. The Plan says the claims for these services have not been denied.  Rather, the claims processed and assessed the member's applicable 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $587 copayment per day for days 1-3, and a $0 copayment for days 4-90 for inpatient psychiatric facility services.  Records show that the enrollee was in the facility for 15 days.  The enrollee was charged a $587 copayment per day for the first three days, for a total of $1761.  None of the additional days had a copayment assessed. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient psychiatric facility services provided from May 17, 2021, to June 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (AED) you rented from May 11, 2021, to June 11, 2021.  You asked the Plan to waive the coinsurance for the AED. You say that you cannot afford this coinsurance. 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 durable medical equipment.   You have been asked to pay 20% coinsurance for the AED. The AED falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator (AED) you rented from May 11, 2021, to June 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the chest x-ray you received from an out-of-network provider on June 2, 2021.  You asked the Plan to waive the coinsurance for the chest x-ray. You say that you think the Plan should pay for this service in full. 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 50% coinsurance for basic radiological services with an out-of-network provider.   You have been asked to pay 50% coinsurance for the chest x-ray. The provider from whom you received this x-ray is an out-of-network provider.  Therefore, the chest x-ray falls within the basic radiological services with an out-of-network provider benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the chest x-ray you received from an out-of-network provider on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for one of the dental x-rays (code D0230) you received on June 29, 2021.  You asked the Plan to pay for the dental x-ray. You say that you haven't been to a dentist since the pandemic hit.  You had to go to a new dental office, and they required these x-rays. The Plan denied your request. The Plan says you have exceeded your benefits for dental x-rays.  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.  Records show that you received numerous dental services on this date of service.  In addition to the dental x-ray that was denied (D0230), the Plan paid for another dental x-ray you had on that date (code D0220). Your Plan contract explicitly states that you are only covered for one procedure code per calendar year for intraoral x-rays.  That benefit was exhausted when the Plan paid for code D0220. That is why the dental x-ray coded as D0230 is not covered. Therefore, we decided that the Plan does not have to pay for one of the dental x-rays (code D0230) you received on June 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on June 2, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the OON psychotherapy services. You say that the provider shouldn't be punished for the facility's failure to get authorization. The Plan denied your request. The Plan says unauthorized, non-plan care 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. It is each provider's obligation to confirm insurance coverage prior to rendering services. 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 psychotherapy services provided on June 2, 2020, by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical pathology services provided on February 23, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.    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 surgical pathology services provided on February 23, 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 emergency room services and inpatient hospital services rendered from January 8, 2021, to January 22, 2021.  You asked the Plan to waive the copayment for emergency room services and inpatient hospital services. You say that you never had occupational or speech therapy. You also say that you only had physical therapy and it lasted about 40 minutes. You also say you did not have physical therapy every day. The Plan denied your request. The Plan says you were 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 $90 copayment per visit for emergency care, which is not waived if admitted to inpatient hospital. You contract with the Plan also clearly says that you must pay a $250 copayment per day for days 1-7 per admission for inpatient hospital care.   You have been asked to pay a $90 copayment for emergency room services. You also have been asked to pay a $250 copayment for inpatient hospital services for days 1-7 for a total of $1,750 ($250 copayment x 7 days.  = $1,750. The record shows the copayments are for emergency room services and for inpatient hospital services and are not related to occupational and speech therapy. 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 and inpatient hospital services rendered from January 8, 2021, to January 22, 2021.   Your complaint about potentially being charged for services not received 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on August 21, 2020.  You asked the Plan to pay for the services provided. You say that this is one of the most effective chronic pain relief therapies. The Plan denied your request. The Plan says naturopathic services are not covered under any condition.  The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.   We looked at the file and the rules. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Furthermore, The services at issue in this appeal are naturopathic services, which are not covered by Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pay for the pain management services provided on August 21, 2020.