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

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
June 16, 2021, to June 24, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with how 
high the charges are. 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 $275 
copayment for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from June 16, 2021, to June 24, 2021. Therefore, you are responsible to pay 
a $275 copayment for days 1-6 (June 16, 2021, to June 21, 2021).  
The total amount you owe is: $275 (copayment) x 6 (inpatient days) = $1,650.  
 
You have been asked to pay the total copayment amount of $1,650 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 an inpatient hospital stay provided from June 16, 2021, to June 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D3431).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D3431).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene panel testing billed for services provided on March 8, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. The claim shows a date of service of March 8, 2021. However, the records provided show the specimen was collected on March 17, 2021. The billed services are not supported by the medical documentation. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel testing billed for services provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is 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 drug testing provided on July 23, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy visits provided on July 9, 2021, to July 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the physical therapy visits. You say that the enrollee has a Medicare dual plan and is entitled to all Medicare-approved services. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the physical therapy visits provided on July 9, 2021, to July 28, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fine needle aspiration provided on 
December 10, 2020. 
 
You asked the Plan to waive the copayment for a fine needle aspiration. You say that you disagree with the 
charges for the procedure. 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 $100 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You received a fine needle aspiration at an outpatient hospital facility on December 10, 2020. A fine needle 
aspiration is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $100 
copayment.  
You have been asked to pay a $100 copayment for a fine needle aspiration. A fine needle aspiration falls within 
the outpatient surgery and other medical 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 fine needle aspiration 
provided on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transfer bench provided on May 10, 2021.

You asked the Plan to pay for the transfer bench. You say that it is hard to lift your legs into the tub. The Plan denied your request. The Plan says the request is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

We looked at the file and the rules. The Plan does note that per phone calls with the provider company, you will not be responsible for payment of this item. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the transfer bench provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220)
and limited oral evaluation - problem focused (D0140) provided July 5, 2021.
You asked the Plan to pay for the intraoral x-rays and limited oral exam. You say that you would like the
services covered. The Plan denied your request. The Plan says these services are not covered under your
benefits.
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 intraoral - periapical first radiographic image (D0220) and limited oral evaluation - problem focused (D0140)
provided July 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the breast surgery you had with an out-of-network provider on March 22, 2021.
You asked the Plan to waive the deductible for the out-of-network breast surgery. You say that this surgery was needed due to leaking breast implants. You said that you were told that insurance would pay for this. The Plan denied your request. The Plan says you had not met your deductible at the time of these services.
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 there is a $1000 deductible which applies to out-of-network services. The services you received were out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network breast surgery was received on March 22, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for the breast surgery you had with an out-of-network provider on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided from March 11, 2021, to March 12, 2021.
You asked the Plan to pay for self-administered drugs. You say that you would like to be reimbursed regarding the medications administered while you were in the hospital from March 11, 2021, to March 12, 2021. The Plan denied your request. The Plan says you were charged the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided from March 11, 2021, to March 12, 2021.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88342) provided on December 31, 2020.
You asked the Plan to pay for code 88342. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88342
is a column II code to column I code 88189. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service (88342) provided on December 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve moderate sedation services (D9243 and D9239).
You asked the Plan to pre-approve moderate sedation services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under the Plan's supplemental 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. 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 pre-approve moderate sedation services (D9243 and D9239).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified prosthodontic procedure (D5899) provided on June 10, 2021.
You asked the Plan to pay for an unspecified prosthodontic procedure. You say that a Plan representative informed you that the provider of the services at issue is an approved provider. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an unspecified prosthodontic procedure (D5899) provided on June 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from May 3, 2021, to May 12, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you met your out-
of-pocket maximum on April 30, 2021, so you should not have to pay anything. 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 $305 
copayment per day for days 1-6, and a $0 copayment for days 7-90 for inpatient hospital care.  
 
You have been asked to pay a 635.19 copayment for the inpatient hospital services. The records show that at 
the time this claim processed, you still had $635.19 remaining on your out-of-of-pocket maximum. Although 
your contract says that you pay a $305 copayment per day for the first 6 days of your inpatient hospital stay, 
you have only been charged this remaining $635.19 amount. 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 inpatient hospital services you received from May 3, 2021, to May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81238, 81286, 81410, 81411, 81439) provided on February 22, 2021.
You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not ordered by the physician.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81238, 81286, 81410, 81411, 81439) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on June 22, 2021.
You asked the Plan to pay for a physician visit. You say that you rely on the facility to obtain the necessary authorizations. You say the services were medically necessary. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization or referral from a contracted provider. The Plan says the services were not urgent 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 a physician visit provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on April 18, 2021.
You asked the Plan to pay for a home visit. You say that your services do not require prior authorization. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization or referral from a contracted provider. The Plan says the services were not urgent 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 a home visit provided on April 18, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for two emergency room visits from December 19, 2020, to December 21, 2020.

You asked the Plan to waive the copayment for emergency room visits. You say that you were seen in the emergency room on December 19, 2020 and returned within 24 hours. You say the provider refunded you $120 but then you later received a bill you feel was sent in error. The Plan denied your request. The Plan says the cost-share was applied correctly. The Plan found you were admitted for two different conditions, which means the copayment is applied to both visits. The Plan also spoke to a representative for the provider about the refund and found the $120 was transferred under another balance on your account, but it was not refunded.

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 $120 copayment for Emergency Care.

You have been asked to pay a $240 copayment for two emergency room visits ($120  2 visits = $240), which fall within the Emergency Care benefit category. The Plan contract says you do not pay the cost-share if you are re-admitted within 24 hours for the same condition, but the record shows your visits were for different conditions. 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 two emergency room visits from December 19, 2020, to December 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with polyp removal you had at an outpatient hospital facility on June 7, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy with polyp removal. You say that this was your routine colonoscopy and it shouldn't have been coded as diagnostic. 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 $100 copayment for outpatient surgery at an outpatient hospital facility.
The Plan contract says that you are covered for one screening colonoscopy every 10 years with no cost sharing. However, if any abnormality is found, the procedure is no longer a screening, and you will be responsible for the outpatient surgery copayment. In this case, since you had polyps removed, that means that abnormalities were found. This means that the colonoscopy you had is considered a diagnostic procedure and the outpatient surgery copayment applies. 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 diagnostic colonoscopy with polyp removal you had at an outpatient hospital facility on June 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

ded that the Plan does not have to waive the copayment for ambulance services you received on May 17, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that the hospital told you not to worry about this bill. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($212.25) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan says that they confirmed with the hospital that they did not advise you that they would cover your ambulance trip.
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 $250 copayment per trip for ambulance services. You have been asked to pay a $250 copayment per trip for the ambulance 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 ambulance services you received on May 17, 2021.