Persius/hicric huggingface dataset:
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 June 23, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you did not go to the ER first. You said that you were having outpatient surgery and had complications, so you were transported to the ER. 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 for emergency room visits. You have been asked to pay a $50 copayment for the ER visit. It isn't clear why the Plan has charged a $50 copayment instead of the applicable $65 copayment for ER services. However, because the Plan is entitled to charge up to $65, they have not overcharged you. This copayment applies regardless of the reason 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 on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical traction equipment received on April 16, 2021.

You asked the Plan to pay for the cervical traction equipment. You say that you were informed that you could purchase the equipment from this provider. The Plan denied your request. The Plan says the item is not a covered benefit when provided by a provider that does not participate in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the cervical traction equipment received on April 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation hospital services you received from March 28, 2021, to April 4, 2021.

You asked the Plan to waive the copayment for the inpatient services. You say that you do not know what these charges and are you cannot afford this bill. 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 per day for days 1-5, and a $0 copayment for additional days for inpatient rehabilitation hospital care.

Records show that you were in the inpatient rehabilitation hospital for seven days. For the first five days, you were charged a copayment of $295 per day, for a total of $1475. You were not charged a copayment for the additional days. 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 rehabilitation hospital services you received from March 28, 2021, to April 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder procedure you had at an outpatient hospital clinic on March 2, 2021.

You asked the Plan to waive the copayment for the bladder procedure. You say that you received two claims for this procedure: one from the doctor, and one from the clinic. You believe this is double billing. You also say that you were treated in the clinic and not a hospital. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were not charged any cost sharing for the physician's portion of this service. You were only charged a copayment for the facility services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment for outpatient services not performed in an ambulatory surgical center.

You have been asked to pay a $275 copayment for the bladder procedure. You had this procedure at an outpatient hospital clinic. Your Evidence of Coverage states that the $275 copayment applies if you receive the procedure at any location other than an ambulatory surgery center. Because the outpatient hospital clinic is not an ambulatory surgical center, the copayment applied correctly. In addition, the physician and the facility are permitted to charge separately for their portion of the services you received. It is not double billing and you are not responsible for separate cost sharing. 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 bladder procedure you had at an outpatient hospital clinic on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on April 20, 2021.

You asked the Plan to pay for the dental services. You say that you called the plan to request a provider. The Plan denied your request. The Plan says the services received are 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 pay for the dental services provided on April 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen equipment you rented from April 5, 2021, to June 5, 2021.

You asked the Plan to waive the coinsurance for the oxygen equipment. You say that your medical equipment for many years was sold to a different company. You said that you had never received a bill for your oxygen equipment in the past and now you're getting a monthly bill. 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 oxygen equipment. The oxygen equipment falls within the durable medical equipment benefit category. This cost sharing 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 coinsurance for the oxygen equipment you rented from April 5, 2021, to June 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on January 27, 2021, by a Medicare opt out provider.
You asked the Plan to pay for the crown. You say that when you signed up for this plan you were advised that you had a $400 dental allowance and that your dentist was a preferred provider. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective January 26, 2016, to January 26, 2022, and there was no authorization for the dental work. The Plan also says that you did not ask about this provider's status or for help locating a dentist who accepts Medicare when you contacted the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on January 27, 2021, by a Medicare opt out provider.
Your complaint about possibly being misinformed by the Plan 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on April 7, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that you could have driven to the hospital yourself, so you shouldn't have to pay this copayment. 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 $250 copayment for ambulance services. 

You have been asked to pay a $250 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 April 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery services rendered by the out-of-network (OON) provider on June 3, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient surgery services rendered by the out-of-network (OON) provider on June 3, 2021.
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 19, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that this was your annual wellness visit and you should not owe a 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 $50 copayment for services provided by a specialist. 

The medical records show that you received services beyond a preventative screening on May 19, 2021. Therefore, you are responsible to pay the $50 copayment.

You have been asked to pay a $50 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 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on January 23, 2021.
You asked the Plan to pay for code 81455. 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. We looked at the file and Medicare rules. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel represented by code 81455 provided on January 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 28, 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 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. 

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 19, 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 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. We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you had from January 11, 2021, to January 26, 2021.

You asked the Plan to waive the copayments for the PT services. You say that you started PT in 2020 but had to stop because you were hospitalized. You stated that you restarted your visits and assumed that they were authorized to not require a copayment. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that there are no phone records showing that you were ever advised these services would be covered with no copayment.

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 per visit for physical therapy.

You have been asked to pay a $35 copayment per visit for each of the PT services, for a total of 10 visits ($350). 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 physical therapy (PT) services you had from January 11, 2021, to January 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 25,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that you feel that the charges are
too high for a transport of only 12 miles. 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 ambulance services.
You have been asked to pay the allowed amount of $222.65, which is less than the $275 copayment for
ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for services you had at a dermatologist's office on April 8, 2021, and April 20, 2021.
You asked the Plan to waive the copayments for the dermatology services. You say that you did not have these services. 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 visits to a specialist's office. We looked at the medical records from the dermatologist. They show that on April 6, 2021, you were seen for two reasons: skin discoloration on the left and right cheek, and for skin lesions. The records on that date show that you had 15 keratoses treated with liquid nitrogen. You also had a neoplasm on the left side of your neck that was evaluated. You proceeded to have a shave biopsy of this neoplasm. Medical records show that you returned to the office on April 8, 2021, for a follow-up from the nitrogen treatment and the biopsy. You were advised during that visit to follow up once more to check the progress of your healing. You returned to the office on April 20, 2021, for this next follow-up visit. You have been asked to pay a $15 copayment for the visits on April 8, 2021, and April 20, 2021. These dermatology services fall within the visits to a specialist'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 copayments for services you had at a dermatologist's office on April 8, 2021, and April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on February 21, 2021.

You asked the Plan to pay for the radiology 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 providers must report services correctly.

We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate
claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of
service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the
Plan does not have to pay for the radiology services provided on February 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on April 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the radiology services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 radiology services provided on April 5, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on April 28, 2021.
You asked the Plan to pay for the continuous glucose monitor. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a valid proof of delivery was not provided.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP device provided on July 3, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the CPAP device. You say that 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 CPAP device provided on July 3, 2021, by an out-of-network (OON) provider.