Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health aide services provided from April 12, 2021, to May 27, 2021.  You asked the Plan to pay for the home health care. You say that you were not aware that you needed an order from a physician for the services. You also say that no one explained the requirements.  The Plan denied your request. The Plan says there is no physician order that was filed prior to the dates of service in this case. The Plan also says that the services received are custodial in nature.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   The file shows that skilled nursing or therapy services were not provided during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the home health aide services provided from April 12, 2021, to May 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on July 4, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that the bill states "out-of-network", but this should be covered anyway. You said that your husband had an ambulance service previously and you did not have to pay for it. The Plan denied your request. The Plan says this claim was not denied for "out-of-network". Rather, the bill represents your applicable cost sharing.
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 $240 copayment for emergency ambulance services. The enrollee has been asked to pay a $240 copayment for the ambulance services. This copayment applies regardless of what you may have paid in the past for similar services. 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 the ambulance services provided on July 4, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on August 9, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER to see a hand doctor because of an injury to your right hand index and middle fingers. you stated that you checked in and waited 6 hours. You then checked out of the ER when you were able to get an appointment with an orthopedist. You do not think you should have to pay a copayment because you were never seen by any medical personnel. 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 $65 copayment per visit for emergency room services. You have been asked to pay a $65 copayment per visit for the ER visit. This copayment applies each time you go to the ER, regardless of the extent of 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 copayment for the emergency room (ER) visit you had on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and simple extraction (D7140) provided on August 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay more for the problem focused limited oral evaluation, first intraoral periapical x-ray, and simple extraction. You say that you contacted the Plan and were advised that the dentist was in-network and the procedures would be covered. The Plan denied your request. The Plan says these services were rendered by a non-participating provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 more for the problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), and simple extraction (D7140) provided on August 6, 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 urgently needed services provided on July 16, 2021.  You asked the Plan to waive the copayment for urgently needed services. You say that your primary care physician was not available and you were under the impression that you would only owe a primary care copayment. You state that you were not informed that you would owe a specialist copayment or urgent care copayment. 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 urgently needed services.   You have been asked to pay a $35 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on July 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the esophagogastroduodenoscopy (EGD) you had at an outpatient hospital facility on June 14, 2021.
You asked the Plan to waive the deductible for the EGD. You say that this endoscopy is equally important to the colonoscopy you had, so it should be covered in full. The Plan denied your request. The Plan says you were charged this deductible correctly.
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 outpatient surgery and services at an outpatient hospital facility. The EGD falls within the benefit category of outpatient surgery and services at an outpatient hospital facility. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to outpatient surgery and services at an outpatient hospital facility. Although the EGD may be medically necessary and appropriate, there is nothing in your contract that says that this procedure is covered at no cost to you. This cost sharing is a contractual obligation that had not been met at the time the EGD was
received on June 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the esophagogastroduodenoscopy (EGD) you had at an outpatient hospital facility on June 14, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 26, 2021.  You asked the Plan to pay for the laboratory services. 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.  The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.  We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iStent.
You asked the Plan to pre-approve iStent. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that in summary, Palmetto GBA considers one iStent, iStent inject (device capable of delivering two individual iStents per eye), medically reasonable and necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being treated with an ocular hypotensive medication and the procedure is being performed in conjunction with cataract surgery. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve iStent. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not indicate that the enrollee is being treated with with an ocular hypotensive medication. The elements of the coverage criteria are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of iStent have not been met. Therefore, we decided that the Plan does not have to pre-approve iStent.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge preservation - per site (D7953) provided August 23, 2021.  You asked the Plan to pay for the guided tissue regeneration and bone replacement graft. You say that the services were necessary for your bridge to be made. 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 guided tissue regeneration - resorbable barrier, per site (D4266) and bone replacement graft for ridge preservation - per site (D7953) provided August 23, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had from August 18, 2021, to August 19, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you became ill at home and were taken by ambulance to the hospital.  While there, you had a computed tomography (CT) scan.  You do not think you should have a copayment for the CT scan. The Plan denied your request. The Plan says you were not charged a copayment for the CT scan.  Rather, the $90 copayment you were charged is for the ER visit.  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 for emergency room services.   You have been asked to pay a $90 copayment for the ER 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 emergency room (ER) visit you had from August 18, 2021, to August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received at an outpatient
hospital facility on July 21, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you had these labs taken at
doctor's office, not a hospital. 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 $50
copayment for lab services at an outpatient hospital facility.
You have been asked to pay a $50 copayment for the lab services. The facility where you had the blood drawn
and the facility where the labs were processed both bill as outpatient hospital facilities. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for lab services you received at an outpatient hospital facility on July 21,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and topical application of
fluoride varnish (D1206) provided August 17, 2021.
You asked the Plan to pay for the dental cleaning and fluoride varnish. You say that you would like the bill
submitted to Medicaid. The Plan denied your request. The Plan says you have exceeded frequency limits for
these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental
cleaning and fluoride varnish when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The Plan provided documentation showing that a dental cleaning and
fluoride varnish were previously covered on both January 6, 2021, and May 6, 2021. Based on this information,
we decided that the Plan's frequency limits for coverage of the dental cleaning and fluoride varnish have been
exceeded. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) and
topical application of fluoride varnish (D1206) provided August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 5, 2021.
You asked the Plan to pay for the limited oral exam. You say that you are entitled to a $3,000 dental benefit. The Plan denied your request. The Plan says you have exceeded the frequency limit for these services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that coverage was provided for a limited oral exam provided July 19, 2021. Based on this information, we decided that the Plan's
frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from April 20, 2021, through April 25, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day, for days 1-7 for inpatient hospital care.   The enrollee has been asked to pay $1,125 ($225 copayment x 5 days) for the inpatient hospital care provided. 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 the inpatient hospital care provided from  April 20, 2021, through April 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tier exception for Monovisc.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the drug is not eligible for a tier exception.  The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for tier exceptions.  We looked at the file and Medicare rules. The requested drug, Monovisc, is covered by Part B Medicare and is not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Monovisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown and core buildup provided on June 22, 2021.  You asked the Plan to pay for the crown and core buildup. You say that the crown is the first permanent restoration not a replacement. You say that the claim has been completed and you want the issue resolved. The Plan denied your request. The Plan says the services are not covered 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 crown and core buildup provided on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on July 7, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you have never had to pay a copayment for radiology services before. 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 $150 copayment for CT scans.   You have been asked to pay a $150 copayment for the CT scan. This copayment applies regardless of what you may have paid in the past. 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 computed tomography (CT) scan of the chest you had on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for physical therapy services you received on May 25, 2021.  You asked the Plan to waive the coinsurance for the physical therapy services. You say that you do not believe you should have to pay this amount. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The Plan says that your level of Medicaid eligibility does not cover your cost sharing.  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 physical therapy services.   You have been asked to pay 20% coinsurance for the physical therapy 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 coinsurance for physical therapy services you received on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on July 23, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on July 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient surgery you had at an outpatient hospital facility from August 2, 2021, to August 3, 2021.  You asked the Plan to waive the copayment for the outpatient surgery. You say that you cannot afford this copayment.  You said that if you had known the cost, you would not have had the surgery. 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 $295 copayment for outpatient surgery at an outpatient hospital.   You have been asked to pay a $295 copayment for the outpatient 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 outpatient surgery you had at an outpatient hospital facility from August 2, 2021, to August 3, 2021.