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

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 27, 2021, to June 7, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were already in another hospital from May 11, 2021, to May 27, 2021, and you had to pay a copayment on that claim. You stated that you should not have to pay a second copayment because you changed hospitals. 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 $175 copayment per day for days 1-7, and a $0 copayment for additional days, per admission for inpatient hospital care.  Records show that you were in the hospital for 11 days. You were charged a $175 copayment per day for each of the first 7 days, for a total of $1225. Your Evidence of Coverage explicitly states that this copayment is charged per admission, regardless of the reason for the admission. You had two separate admissions to two different hospitals, so two copayments can apply. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services you received from May 27, 2021, to June 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had on April 23, 2021.  You asked the Plan to waive the copayment for the EKG. You say that you don't understand this bill. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($13.04) 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 $30 copayment for non-radiological diagnostic services.   You have been asked to pay a $30 copayment for the EKG. The EKG falls within the non-radiological diagnostic services benefit category. This copayment applies regardless of where these services take place. 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 electrocardiogram (EKG) you had on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary, because the enrollee has difficulty walking. The Plan denied your request. The Plan says this is needed for use outside of the home.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 the wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found your mobility deficit is not revealed to impair MRADLs in the home. While you may be able to safely operate a manual wheelchair, the documentation does not reveal that the requested manual wheelchair will significantly improve MRADLs in the home. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.

You asked the Plan to pre-approve a grab bar. You say that this is for support while showering. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  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 self-administered drugs are not covered.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the LifeVest you rented from May 7, 2021, to August 8, 2021.  You asked the Plan to waive the coinsurance for the LifeVest. You say that the cost of this device is not affordable.  You stated that the cost sharing should be reduced. The Plan denied your request. The Plan says you were charged this cost sharing 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 LifeVest. The LifeVest falls within the durable medical equipment 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 coinsurance for the LifeVest you rented from May 7, 2021, to August 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray rendered on August 20, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 71045 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 71045 (chest x-ray, single view) and 71046 (chest x-ray, two views). Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on August 20, 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 8, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER and you never saw a doctor or a nurse.  You said that an aide came and did a urine test.  You stated that you waited a long time and finally left, so you should not 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 $90 copayment for emergency room visits.   You have been asked to pay a $90 copayment for the ER visit. This copayment applies each time you visit 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 July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 27, 2021, to August 31, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that this was an emergency and you did not have a choice. 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 $210 copayment per day for days 1-7 for inpatient hospital care.   Records show that you were in the hospital for 4 days.  You were charged a $210 copayment per day, for a total of $840. This copayment applies regardless of the reason for the inpatient stay. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services you received from August 27, 2021, to August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the member liability for the partial lower denture (D5214) provided on June 30, 2021.  You asked the Plan to waive the member liability for the dental item. You say that you should not be responsible for this bill. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services are paid up to a certain amount. The Plan says that when you receive services out of network, you are responsible for any amount greater than what the Plan pays. 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 partial lower denture is listed as covered, out of network dentists may bill you for any amount greater than what the Plan pays. The record shows that the Plan paid $730 of the $1,765 total billed amount. $1,765 - $730 = $1,035. Therefore, we decided that the Plan does not have to waive the member liability for the partial lower denture (D5214) provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and pontics (D6245 x 4) provided on August 30, 2021.  You asked the Plan to pay for the dental services. You say that your bridge no longer fits. You say that you have trouble eating. You also say that your dentist recommended you get a bridge. The Plan denied your request. The Plan says retainer crowns and pontics are not listed as covered 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, the retainer crowns and pontics are not among those covered under this benefit. Additionally, the record shows that you were aware that the services would not be covered before you received them. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and pontics (D6245 x 4) provided on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional six surgical extractions (D7210 x6) provided on August 12, 2021.  You asked the Plan to pay for the additional extractions. You say that you believe these services were medically necessary for your well-being. You also say that you were unaware of the 3-extraction limit. The Plan denied your request. The Plan says these services have exceeded the frequency limitation of your Plan within the twelve-month period.  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, you are limited to up to 3 surgical extractions every calendar year. The record shows that you received 9 surgical extractions (D7210 x9) on August 12, 2021, three of which were covered by the Plan, and your surgical extractions benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional six surgical extractions (D7210 x6) provided on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory work provided on August 3, 2020, to August 17, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory work. You say that you were under the impression that you did not need a referral. 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. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on August 3, 2020, to August 17, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), and an extraction (D7210).  You asked the Plan to pre-approve a limited oral evaluation, and an extraction. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not covered unless they are performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.  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.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, and an extraction have not been met. Specifically, the services at issue are not covered unless they are performed by a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), and an extraction (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the urgent care visit you had on July 3, 2021.  You asked the Plan to waive the copayment for the urgent care visit. You say that you had an eye infection that needed immediate attention.  You stated that you went to your regular clinic, but they were closed without prior notification.  You had to go to urgent care instead, so you don't feel as though you should have to pay the 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 $40 copayment for urgent care visits.   You have been asked to pay a $40 copayment for the urgent care visit. This copayment applies regardless of the reason for the 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 urgent care visit you had on July 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to adjust the copayment applied to physical therapy services provided on June 16, 2021.  You asked the Plan to adjust the copayment applied to the physical therapy services. You say that the provider you saw was in network and you should only have a $30 copayment for the visit. The Plan denied your request. The Plan says the appropriate copayment was applied 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). Your contract with the Plan clearly says that you must pay a $55 copayment for Medicare covered physical therapy visits provided out-of-network.   The case file shows that the provider you saw for the physical therapy services in dispute is non-contracted with the Plan and is considered an out-of-network provider. You have been asked to pay a $55 copayment for the physical therapy services. The physical therapy services fall within the Medicare covered physical therapy visits provided out-of-network 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 adjust the copayment applied to physical therapy services provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional extractions provided on August 11, 2020.  You asked the Plan to pay for the additional extractions. You say that your agent said that insurance would be the one to cover these services. The Plan denied your request. The Plan says you are responsible for any amount above the $1,500 dental maximum per calendar year.    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, you also have a Plan maximum of $1,500 for covered dental services per year. The Plan paid $1,500 toward the extractions received on August 11, 2020, which exhausted your benefit. You are responsible for any amount above the $1,500 dental maximum per calendar year. Therefore, we decided that the Plan does not have to pay for the additional extractions provided on August 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on May 17, 2021.  You asked the Plan to pay for the dental services. You say that you were advised by a plan representative that crowns were covered at 100%. You say that you called in good faith to make sure the services would be covered. You say that you were given incorrect information. You also say that the services should be covered. The Plan denied your request. The Plan says there is an annual maximum benefit of $1,000 for covered dental services. The Plan says that this benefit has been exceeded. The Plan also says that no misinformation was provided prior to the services being provided.    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, the annual maximum benefit has been exceeded. The record shows that the Plan paid $172 for dental services you received on March 8, 2021, and $828 for dental services received on March 22, 2021. $172 + $828 = $1,000. Additionally, the record shows that the claims for services you received in March were paid on June 10, 2021. As such, the information provided by the plan representative on April 5, 2021, was correct. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drugs or medicaments (D9630) provided on July 30, 2021.  You asked the Plan to pay for the drugs or medicaments (D9630). You say that you want to know why the request was denied. The Plan denied your request. The Plan says the 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 drugs or medicaments (D9630) provided on July 30, 2021.