Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture (D5120) and to pay more
for the complete maxillary denture (D5110) provided on March 17, 2021.
You asked the Plan to pay for the complete mandibular denture or pay more for the complete maxillary
denture. You say that you were misled into thinking these services would be paid in full and would like them to
be covered. The Plan denied your request. The Plan says the maximum allowed for the 2021 calendar year has
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 Plan offers a maximum plan benefit coverage amount of $500 per year. The contract clearly states that you are responsible for any cost above the $500 maximum. The record shows that you met the annual maximum benefit while processing this claim for the March 17, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete mandibular denture (D5120) and to pay more for the complete maxillary denture (D5110) provided on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound you had at an outpatient hospital facility on October 26, 2021.
You asked the Plan to waive the copayment for the breast ultrasound. You say that in previous years, you have only paid a $40 copayment for this service. 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 ($97.44) is less than your copayment obligation, you are responsible for the full allowed 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 diagnostic tests at an outpatient hospital facility. You have been asked to pay a $100 copayment for the breast ultrasound. The breast ultrasound falls within the diagnostic tests at an outpatient hospital facility benefit category. The facility where you received this service is
considered an outpatient hospital facility. 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 breast ultrasound you had at an outpatient hospital
facility on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth office visit (99202) provided January 28, 2021.
You asked the Plan to pay for the office visit. You say that the treatment sought was medically necessary to
treat the enrollee based on the enrollee's medical condition. The Plan denied your request. The Plan says
evidence of misrepresented service, The services are not supported in the medical records received
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, the CPT Code Manual definition of code 99202 is an Office or other outpatient visit for the
evaluation and management of a new. patient, which requires these 3 key components: An expanded problem
focused history; An expanded problem focused examination; Straightforward medical decision making.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the office visit. Our reviewer says that the medical records
provided did not support the medical necessity of the services provided. Our reviewer found the reviewed
documentation indicates that research of the claims history reveals the member has never been seen by this
group. Outreach made to the enrollee and unable to confirm if this visit actually took place. Per TIPS Noble
Telehealth tax ID XXXXXXXXX is engaged in a Telemarketing Scheme and enrollee has no knowledge of billing
Provider.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not
have to pay for a telehealth office visit (99202) provided January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that were unable to obtain prior authorization as you are not a contracted provider. You also say that you performed a clinically relevant proprietary test not available from any other laboratory. The Plan denied your request. The Plan says the services were rendered by non-participating providers, and the Plan did not receive a primary care physician (PCP) referral to review and approve. The Plan also says that the referring provider was also a non-participating provider and they also have determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on September 29, 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 the office visit you had with an orthopedic surgeon on March 9, 2021.
You asked the Plan to waive the copayment for the specialist visit. You did not provide a reason for your appeal in the letter you sent to the Plan. 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 $40 copayment for visits with a specialist. You have been asked to pay a $40 copayment for the specialist 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 office visit you had with an orthopedic surgeon on March 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs you received from September 29, 2021, to October 6, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were under the impression that these drugs would be covered 100% because they were related to cancer. The Plan denied your request. The Plan says you were charged this coinsurance correctly. Please note that the Plan has waived the copayments for the facility services received on these dates of service, so you are only being charged the coinsurance for the drugs.
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 chemotherapy drugs.
You have been asked to pay 20% coinsurance for the chemotherapy drugs. 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 chemotherapy drugs you received from September 29, 2021, to October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit you had with a plastic 
surgeon on November 22, 2021. 
 
You asked the Plan to waive the copayment for the plastic surgery visit. You say that you believe this 
copayment should be waived.  You said that this appointment was to have stitches removed and to check your 
nose.  You said that you were only seen for three minutes and told to call your primary care doctor to remove 
the stitches. 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 $45 
copayment for visits to a specialist's office.  
 
You have been asked to pay a $45 copayment for the plastic surgery visit. This copayment applies each time you visit a specialist's office, regardless of the length of the visit or the extent of services you receive. 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 office visit you had with a plastic surgeon on November 
22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ultrasound of the heart you had on October 22, 2021.
You asked the Plan to waive the deductible for the ultrasound. You say that you do not believe you should have to pay the full amount for this test. You said that this test was done to determine if you had a leaky heart. 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 $1,000 deductible which applies to outpatient diagnostic radiology services. The ultrasound you had is an outpatient diagnostic radiology service. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to outpatient diagnostic radiology services. This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received on October 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the ultrasound of the heart you had on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) radiologic examination, spine, lumbosacral (72100) radiologic examination, spine, cervical (72040) provided October 4, 2021.
You asked the Plan to pay for the chiropractic services. You say that the provider told you that you had to take x-rays and you were only responsible for $20. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203) radiologic examination, spine, lumbosacral (72100) radiologic examination, spine, cervical (72040) provided October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for facet joint injections performed on 
September 23, 2021, and November 18, 2021. 
 
You asked the Plan to waive the copayments for the injections. You say that you feel the charges are too high 
and they should all be considered one procedure. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery services.  
 
You have been asked to pay a $250 copayment for each of the injections, for a total of $500. Please note that 
these procedures still involve the use of a surgical room and preparation. The injections fall within the Outpatient Surgery, Including 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 copayments for facet joint injections 
performed on September 23, 2021, and November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit 
provided on July 12, 2021. 
 
You asked the Plan to waive the copayment for the PCP office visit. You say that this was an annual visit and 
there should not be a copayment. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $0 for the annual wellness visit. If you receive services that address a medical condition during the same visit, 
additional cost sharing may apply. 
 
Your contract with the Plan also clearly says that you must pay a $10 copayment for each PCP visit. 
 
The record shows that during your visit you addressed issues with intermittent ankle swelling and leg 
numbness. These issues go beyond the scope of the annual wellness visit. Therefore, you have been asked to 
pay a $10 copayment for the PCP office visit. the PCP office 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 primary care physician (PCP) office visit provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery you had on July 22, 
2021. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you have 100% financial 
aid, so you should not be billed for this. The Plan denied your request. The Plan says you were charged this 
copayment correctly.  The Plan says that your financial aid benefit only applies to services rendered at certain 
facilities.  The Plan says that these services were not provided at a facility where your financial aid applies. 
 
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 outpatient surgery.  
 
You have been asked to pay a $325 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 outpatient surgery you had on July 22, 2021.   
Your complaint about the Plans application of financial aid 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EKG provided on September 29, 2021.
You asked the Plan to waive the copayment for an EKG. You say that you disagree with the charges because this was your annual wellness 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 $30 copayment for EKG's.
You have been asked to pay the allowed amount of $13.19, which is less than the $30 copayment for an EKG. An EKG 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 EKG provided on September 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a bed (99199) purchased on August 10, 2021 from an out of
network provider.
You asked the Plan to pay for a bed. You say that you had disk herniation and purchase of a bed and you are
appealing for denial of reimbursement. The Plan denied your request. The Plan says this supplier is not a
Medicare certified provider.
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 a bed (99199) purchased on August 10, 2021 from an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a golf club membership provided on April 1, 2021.
You asked the Plan to reimburse you for the golf club membership. The Plan denied your request. The Plan says a golf club membership was not a covered benefit for your 2021 Plan. In the 2022 coverage for this member's Plan, the fitness benefit was expanded to cover golf as a fitness activity. But this did not take effect until 2022.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
The Plan's rules for coverage of gym benefits have not been met because a golf club membership is not a covered fitness benefit for the 2021 Plan year. Therefore, we decided that the Plan does not have to reimburse you for a golf club membership provided on April 1, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (CT) scan of the cervical spine provided to the enrollee on May 25, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says that the original decision is maintained to not pay for this service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan reprocessed the claim for the computed tomography (CT) scan of the abdomen, pelvis, thoracic, spine, thorax, and lumbar spine, while continuing to deny the scan for the cervical spine. The plan gives no indication of why this specific scan continues to be denied. The plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for the computed tomography (CT) scan of the cervical spine provided to the enrollee on May 25, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the oxygen equipment you received from an
out-of-network provider on November 5, 2021, and November 25, 2021.
You asked the Plan to waive the deductible for the out-of-network oxygen equipment. You say that you have
been using the same provider for years but they have changed their billing name. This had previously been
considered in-network, so you believe it should still be considered in-network. The Plan denied your request.
The Plan says this deductible was applied correctly. The provider ID that this provider bills under now is no
longer a network provider ID with your Plan.
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 $750 deductible which applies to out-of-network durable medical
equipment.
The billing provider is not a network provider with the Plan, regardless of what their network status may have
been previously. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible which applies to out-of-network durable medical equipment.
This cost sharing is a contractual obligation that had not been met at the time the out-of-network oxygen equipment was received on November 5, 2021 to November 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the oxygen equipment you received from an out-of-network provider on November 5, 2021, and November 25, 2021.