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

 We decided that the Plan does not have to waive the copayment for podiatry services provided on October 18, 2021.  

You asked the Plan to waive the copayment for podiatry services. You say that you received a flyer that said that the services would be covered with no copayment. You state that you only received a toenail clipping and no other service was rendered. 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 $45 copayment for podiatry services.   

The medical records show that you received podiatry services on October 18, 2021. Therefore, you are responsible to pay the $45 copayment.   

You have been asked to pay a $45 copayment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0481) provided on September 22, 2021.  

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not pre-approved or emergent. 

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 lab services (G0481) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and needle electromyography provided on August 9, 2021

You asked the Plan to waive the copayments for a specialist visit and needle electromyography. You say that your appointment was cancelled and you did not receive any services. 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 $40 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $30 copayment for non-radiolgoical diagnostic services. 

The medical records show that you received a specialist visit on August 9, 2021. Therefore, you are responsible to pay the $40 copayment. 

The medical records show that you received needle electromyography on August 9, 2021. Therefore, you are responsible to pay the $30 copayment. 

The total amount you owe is: $70.

You have been asked to pay the total copayment amount of $70 for a specialist visit and needle electromyography. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. Needle electromyography falls 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 copayments for a specialist visit and needle electromyography provided on August 9, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gauze (A6219) and the alginate dressing (A6196) rendered by the out-of-network (OON) provider on August 20, 2021.  

You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the supplies 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 items at issue in this appeal. The Plan did not pre-approve the items at issue.  We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the gauze (A6219) and the alginate dressing (A6196) rendered by the out-of-network (OON) provider on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral hygiene instructions (D1330), gingival irrigations (D4921), and periodontal procedures (D4999) provided from May 26, 2021, to September 27, 2021.

You asked the Plan to pay for the oral hygiene instructions, gingival irrigations, and periodontal procedures. The Plan denied your request. The Plan says these services are not covered benefits under your dental 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. Therefore, we decided that the Plan does not have to pay for the oral hygiene instructions (D1330), gingival irrigations (D4921), and periodontal procedures (D4999) provided from May 26, 2021, to September 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 21, 2021, by
an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that the laboratory services were ordered by the
enrollee's physician for the appropriate treatment. The Plan denied your request. The Plan says services
rendered by an out-of-network laboratory and ordered by an out-of-network provider.

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 laboratory services provided on September 21,
2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90834, 90791) provided February 4, 2021 to May 28, 2021.

You asked the Plan to pay for the outpatient mental health services. You say that this service was medically necessary. The Plan denied your request. The Plan says the provider is not eligible for Medicare payment.

The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible for Medicare payment. 

We looked at the file and Medicare rules. The provider at issue is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90834, 90791) provided February 4, 2021 to May 28, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

 We decided that the Plan has to pay for the psychotherapy services (90837) provided on September 7, 2021.  

You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation does not show that the provider consulted the member's attending or primary care physician.  

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. Specifically, the record shows that these services were rendered and billed by a Clinical Social Worker. Medicare rules do not state that Clinical Social Worker's are required to consult the member's attending or primary care physician. The Plan has not forwarded any additional evidence as to why this service is not payable. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837) provided on September 7, 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 waive the copayment for a primary care physician (PCP) office visit
provided on December 15, 2020. We also decided that the Plan does not have to waive the copayment for
laboratory services provided on December 21, 2020.

You asked the Plan to waive the copayments for the PCP office visit and laboratory services. You say that your
primary doctor copayment is $15, not $25. 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 $15
copayment for each primary care doctor visit.

Your contract with the Plan also clearly says that you must pay a $25 copayment for lab services.

The file shows that the Plan adjusted the copayment for the PCP office visit. Therefore, you have been asked to
pay a $15 copayment for the PCP office visit. The PCP office visit and laboratory services falls within the
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to
pay a $25 copayment for the laboratory services. The laboratory services 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 copayment
for a primary care physician (PCP) office visit provided on December 15, 2020. We also decided that the Plan
does not have to waive the copayment for laboratory services provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit provided on April 21, 2021.  

You asked the Plan to waive the copayment for an office visit. You say that the Plan has waived the other copayments for different dates of service. The Plan denied your request. The Plan says 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $15 copayment for each primary care physician's office visit.     

The enrollee has been asked to pay a $15 copayment for an office visit. An office visit falls within Physician/Practitioner services, including doctor's office visits benefit category. 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 an office visit provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for telehealth mental health visits you had from May 11, 2021, to June 8, 2021.

You asked the Plan to waive the copayments for the telehealth mental health visits. You say that you thought these services would be covered in full. 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 $15 copayment for telehealth mental health visits. 

You have been asked to pay a $15 copayment for the telehealth mental health 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 telehealth mental health visits you had from May 11, 2021, to June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on September 27, 2021.

You asked the Plan to waive the copayment for vision care. You say that you should have one free eye exam a year. 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 $0 copayment for annual glaucoma screenings, and eyewear after cataract surgery and a $45 copayment for exams to diagnose and treat diseases and conditions of the eye. 

The medical records show that you received vision care for the diagnosis and treatment of an eye condition on September 7, 2021. Therefore, you are responsible to pay the $45 copayment.

You have been asked to pay a $45 copayment for vision care. Vision care falls within the vision 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 vision care provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99239) provided December 29, 2020.  

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT code 99239 is not supported in the medical record. Specifically, the date of service on the records provided does not match the date of service on the claim. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99239) provided December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on October 27, 2021.

You asked the Plan to waive the copayment for vision care. You say that the provider was not truthful and was unable to treat your condition. 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 $35 copayment for exams to diagnose and treat diseases and conditions of the eyes for vision care. 

You have been asked to pay a $35 copayment for vision care. Vision care falls within the vision 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 vision care provided on October 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99205), a special services procedure (99199), laboratory services (86001, 86003), an office consultation (99243), and antigen therapy services (95165) provided on July 28, 2021, to September 20, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit, a special services procedure, laboratory services, an office consultation, and antigen therapy services. You say that you are trying to get the best medical care you can receive with the encouragement and support of the Plan and providers, in and out-of-network as are your option. You also say that you want to know why your claims have been denied for multiple and what appears to be in network restrictions as well as being based on information you never received. The Plan denied your request. The Plan says Medicare rules say that health plans can require enrollees to get care from network providers and the member's 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 Plan also says that this provider is not a network provider with the Plan and the services were not referred by a network provider. The Plan also says that they have also determined that these services are not urgent or 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 an office visit (99205), a special services procedure (99199), laboratory services (86001, 86003), an office consultation (99243), and antigen therapy services (95165) provided on July 28, 2021, to September 20, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray provided on July 19, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the x-ray. You say that the enrollee was seen in an office setting and the service was 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 x-ray provided on July 19, 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 copayment for a specialist visit provided on May 28, 2021.  

You asked the Plan to waive the copayment for a specialist visit. You say that you were misdiagnosed and would the claim to be reprocessed and paid. 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 $35 copayment for specialist services.   

You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls 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 visit provided on May 28, 2021.