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

We decided that the Plan does not have to waive the deductible for out-of-network nephrology services you received on July 19, 2021.
You asked the Plan to waive the deductible for the out-of-network nephrology services. You say that the Plan has charged you too much and you did not pay the same as last year. The Plan denied your request. The Plan says you had not met your deductible at the time of these services, so you were charged this amount 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 $300 deductible which applies to specialist services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to specialist services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network nephrology services were received on July 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for out-of-network nephrology services you received on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine ophthalmological examination including refraction
provided on July 7, 2021.
You asked the Plan to pay for a routine ophthalmological examination including refraction. The Plan denied
your request. The Plan says the provider is out-of-network and you do not have out-of-network benefits on this
Plan.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers
these services when provided by the Plan's optical provider.
We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the
Plan's optical provider. Based on this information, we decided that the Plan's rules for coverage of a routine
ophthalmological examination including refraction have not been met. Therefore, we decided that the Plan does
not have to pay for a routine ophthalmological examination including refraction provided on July 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services you received from July 1, 2021, to July 28, 2021.
You asked the Plan to waive the copayments for the cardiac rehabilitation services. You say that you were told by customer service that you had no liability. You also said that the provider didn't inform you of this copayment up front. The Plan denied your request. The Plan says the phone records show that you were given correct cost sharing information by customer service. The Plan says that 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 $45 copayment per visit for cardiac rehabilitation services. You have been asked to pay a $45 copayment per visit for the cardiac rehabilitation services. You had seven visits, so you were charged a total of $315. 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 cardiac rehabilitation services you received from July 1, 2021, to July 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the core build up (D2950), crown (D2740), and filling (D2394) provided on July 7, 2021.
You asked the Plan to waive the cost share for the dental services. You say that you believe that the services you received should be paid at 100% with no coinsurance obligation. The Plan denied your request. The Plan says the claim was processed correctly with the 50% coinsurance for restorative dental 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. Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, there is a 50% coinsurance for restorative services. The record shows that the Plan paid $52.47 ($104.97 x 50%) for the core build up, $322.58 ($645.15 x 50%) for the crown, and $74.19 ($148.38 x 50%) for the resin post. $52.47 + $322.58 + $74.19 = $449.23. Coinsurance is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to waive the cost share for the core build up (D2950), crown (D2740), and filling (D2394) provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the crown and core buildup provided on July 6, 2021.
You asked the Plan to pay more toward the crown and core buildup. You say that you were told 50% of the dental services would be covered. You say that are on a fixed income and need help to pay the money back. The Plan denied your request. The Plan says the claim processed correctly.
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, Plan is only obligated to pay 50% of the allowed amount. You are responsible for 50% coinsurance based on the allowed amount of the service and amount greater than the payment made by the Plan to the out-of-network provider. Core buildup remains denied as a non-covered benefit. Therefore, we decided that the Plan does not have to pay more toward the crown and core buildup provided on July 6, 2021.
Your complaint about being misinformed 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health care visit provided on April 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the mental health care visit. You say that the service was performed in good faith. 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 mental health care visit provided on April 13, 2021, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services provided on January 28, 2021.
You asked the Plan to pay for hospital discharge day management services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee ended Medicare Hospice benefits on January 11, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services provided on January 28, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health services you received from December 31, 2020, to January 14, 2021.
You asked the Plan to waive the copayment for the inpatient mental health services. You say that you believe you hit your out-of-pocket maximum for the year, so this should be covered in full. The Plan denied your request. The Plan says you had not met your out-of-pocket maximum prior to these services. The Plan says that 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 per day for days 1-7 and a $0 copayment for additional days for inpatient mental health care. The Plan has provided a full breakdown of your out-of-pocket costs for 2020, and this breakdown confirms that you had not hit your out-of-pocket maximum. That is why a copayment can apply for these services. You received inpatient mental health care for 15 days. You were charged a $250 copayment per day for each of the first 7 days, for a total of $1750. 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 mental health services you received from December 31, 2020, to January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the vision supply, accessory and/or service component for a vision service (V2797) provided on September 7, 2021.  You asked the Plan to pay for the unspecified vision item. You say that you were told your plan covers eyeglasses and you do not understand why this item is not covered. The Plan denied your request. The Plan says this item is not a covered service under your supplemental vision benefit.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eye exams, eyeglasses (lenses and frames) or contact lenses.  We looked at the file and the Plan's rules. The unspecified vision item is not coded/billed or identified as an eye exam, lens, frame, or contact lens. The unspecified vision item is not listed as a covered service by the Plan's supplemental benefit. Therefore, we decided that the Plan does not have to pay for the vision supply, accessory and/or service component for a vision service (V2797) provided on September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an MRI provided on July 27, 2021.  You asked the Plan to waive the copayment for an MRI. You say that you were not aware that you would owe anything. 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 $325 copayment for diagnostic radiology services.   You have been asked to pay a $325 copayment for an MRI. An MRI 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 copayment for an MRI provided on July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Percutaneous transcatheter placement of intracoronary stent (92929) provided on January 7, 2021.  You asked the Plan to pay for code 92929. 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. Code 92929 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the Percutaneous transcatheter placement of intracoronary stent (92929) provided on January 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from May 12, 2021, to July 21, 2021.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were not informed that if you went to another facility you would owe a lesser copayment and you are very unhappy with the Plan's billing practices. 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 outpatient rehabilitation services provided in an outpatient hospital facility.
You received outpatient rehabilitation services from May 12, 2021, to July 21, 2021, for a total of 20 visits.
Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40
(copayment) x 20 (outpatient rehabilitation services) = $800.
You have been asked to pay the total copayment amount of $800 for outpatient rehabilitation services.
Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from May 12, 2021, to
July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for the magnetic resonance imaging (MRI) of the pelvis you had on May 11, 2021, the office visit you had with a radiation oncologist on May 14, 2021, and the radiation therapy services you received from May 14, 2021, to June 17, 2021.  You asked the Plan to waive the cost sharing for the MRI, the specialist visit, and the radiation therapy services. You say that you are requesting reimbursement for your out-of-pocket costs because you say you met your out-of-pocket maximum. The Plan denied your request. The Plan says you were charged these cost sharing amounts correctly because you had not yet met your annual out-of-pocket maximum at the time of these 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 $200 copayment for diagnostic radiology services (other than CT scans), 20% coinsurance for radiation therapy, and a $35 copayment for specialist visits.   The Plan provided a detailed breakdown of your out-of-pocket costs which show that you had not met this maximum until after these services occurred. You have been asked to pay a $200 copayment for the MRI, a $35 copayment for the specialist visit, and 20% coinsurance for the radiation 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 cost sharing for the magnetic resonance imaging (MRI) of the pelvis you had on May 11, 2021, the office visit you had with a radiation oncologist on May 14, 2021, and the radiation therapy services you received from May 14, 2021, to June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim caries arresting medicament application - per tooth (D1354) provided August 10, 2021.
You asked the Plan to pay for the interim caries arresting medicament application. You say that this service was required health care for your teeth. The Plan denied your request. The Plan says this service 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 pay for the interim caries arresting medicament application - per tooth (D1354) provided August 10, 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 July 7, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you should not have to pay this because it was an emergency. 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 $90 copayment per visit for emergency room services.   You have been asked to pay a $90 copayment per visit for the ER visit. 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 July 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on July 20, 2021.
You asked the Plan to pay for code 70450. 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 70450 is a column II code to column I code 70496. 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 computed tomography (CT) scan (70450) provided on July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the EGD provided on April 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the EGD. 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the EGD provided on April 23, 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 July 19, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and you should not be responsible for the charges. 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 visits. You had a specialist visit on July 19, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. 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 July 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transport provided on June 16, 2021.  You asked the Plan to pay for the ambulance transport. You say that this service is not the responsibility of hospice and should be covered by insurance. The Plan denied your request. The Plan says Original Medicare is responsible for payment.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on June 16, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance transport provided on June 16, 2021.