Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for eye surgery provided on September 7, 2021.  You asked the Plan to waive the copayment for the eye surgery. You say that you were told by the Plan that the surgery would only cost you $130. The Plan denied your request. The Plan says the proper copayment was applied for the 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 $300 copayment for outpatient surgery services.     You have been asked to pay a $300 copayment for the eye surgery. The eye surgery falls within the Outpatient hospital 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 eye surgery provided on September 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided on June 29, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you are being billed $53.04 for self-administered drugs. You also say that you received no medications upon your discharge from the hospital. The Plan denied your request. The Plan says you received self-administered drugs that are not Part B 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 pay for the self-administered drugs provided on June 29, 2021.   Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office or other outpatient visit for the evaluation and management of a new patient provided on May 12, 2021.

You asked the Plan to waive the copayment for an office or other outpatient visit for the evaluation and management of a new patient. You say that routine and diagnostic hearing tests are covered at no charge if in network. The Plan denied your request. The Plan says that the claim processed appropriately according to the billing by the provider for services rendered and the structure of your benefit plan. Our records indicate that the hearing services were covered at no charge per your benefit guideline however the specialist office visit was covered with a $30 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 $30 copayment for Physician/Practitioner services, including doctor's office visits, specialist visits.

You have been asked to pay a $30 copayment for an office or other outpatient visit for the evaluation and management of a new patient. The office or other outpatient visit for the evaluation and management of a new patient falls within the Physician/Practitioner services, including doctor's office visits, specialist visit 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 office or other outpatient visit for the evaluation and management of a new patient provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nasal/sinus endoscopy provided on May 11, 2021.

You asked the Plan to waive the copayment for a nasal/sinus endoscopy. You say that you had met the MOOP amount for the year and should not be charged for the service. 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 the MOOP amount for 2021 is $4,500. Your contract with the Plan also clearly says that you must pay a $260 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

You received a nasal/sinus endoscopy at an outpatient hospital facility on May 11, 2021. The record shows that you had not met the MOOP amount for 2021 at the time services were received. Therefore, you are responsible to pay the $260 copayment. 

You have been asked to pay a $260 copayment for a nasal/sinus endoscopy. A nasal/sinus endoscopy falls within the outpatient surgery and other medical 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 copayment for a nasal/sinus endoscopy provided on May 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on August 9, 2021.  You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the claim processed with the correct $300 allowance for the eyeglasses.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  We looked at the file and the Plan's rules. The file shows that the Plan has paid the correct $300 allowance for the eyeglasses. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2332) provided on September 14, 2021.

You asked the Plan to pay for the resin-based composite. You say that for over 10 years the Plan has not paid one dollar for your dental expenses, and you are on a fixed income. The Plan denied your request. The Plan says your $1,000 benefit max was met before the processing of this service.

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 $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on August 5, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2332) provided on September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the resin-based composite - three surfaces, posterior (D2393) provided September 22, 2021.  You asked the Plan to provide additional payment for the resin-based composite. You say that you don't feel you should be liable for the balance billing. The Plan denied your request. The Plan says the cost-sharing was applied 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. The Plan covers the resin-based composite with 20% coinsurance after the $100 deductible is met. You may pay more when you get care from an out-of-network dental provider.   We looked at the file and Medicare rules. The Plan provided documentation showing that they covered 80% of the allowed amount for this service ($16 allowed amount x 80% = $12.80). You are responsible for you $100 deductible and 20% of the allowed amount. Additionally, since the services were received out-of-network, the provider may bill you for the difference between what the Plan paid and the total cost billed by the provider.  Therefore, we decided that the Plan does not have to provide additional payment for the resin-based composite - three surfaces, posterior (D2393) provided September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services (92012) provided on April 29, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for ophthalmological services. You say that upon the patient's request for a vision exam, the nursing facility asked this provider to examine the patient. You also say that the patient did not have any input in choosing who would be his optometrist and the provider does not know which patients he will be seeing since he is assigned to a facility and given a chart of patients in need of his services. The Plan denied your request. The Plan says this claim was denied for failure to obtain the required prior authorization. The Plan also says that they have determined that the services were not urgent or emergent in nature, and the provider is not participating with the member's Plan.  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 ophthalmological services (92012) provided on April 29, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided the Plan does not have to pay for medical services provided to the enrollee on September 10, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 medical services provided to the enrollee on September 10, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for codes 36226, 36218, and 75774 provided on June 28, 2021.  You asked the Plan to pay for codes 36226, 36218, and 75774. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.  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 denied payment for codes 36226, 36218, and 75774. The Plan says code 36226 is a column one to column two code 99223. The Plan says they paid for code 99223, making code 36226 not eligible for payment. However, the Plan provided no evidence that code 99223 was paid for. The file contains no claim showing that payment had been made for code 99223. We find that the Plan has not substantiated their reasoning for denial of payment. Therefore, we decided that the Plan has to pay for codes 36226, 36218, and 75774 provided on June 28, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0483) rendered by the out-of-network (OON) provider on May 11, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0483) rendered by the out-of-network (OON) provider on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on June 18, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 out of network physician services provided to the enrollee on June 18, 2021.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the emergency ambulance services provided on December 19, 2020.  You asked the Plan to pay for the emergency ambulance services. You say that you would like reconsideration because the ambulance services were medically necessary and emergent. The Plan denied your request. The Plan says that the provider did not bill this claim with an appropriate diagnosis code.  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. Specifically, the Plan has denied these services stating that the diagnosis code billed is inappropriate for the services rendered. The Plan has not forwarded a claim or any evidence to indicate what diagnosis code was billed. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the emergency ambulance services provided on December 19, 2020.   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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skin debridement services provided on October 5, 2021.

You asked the Plan to waive the copayment for the skin debridement. You say that you should not be responsible for the copayment since the procedure was medically necessary. 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 $350 copayment for each date of service for surgical procedures provided at an outpatient hospital.

You have been asked to pay a $350 copayment for the skin debridement. The skin debridement falls 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 copayment for skin debridement services provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740), root canal (D3310), and unspecified preventive service (D1999) provided on September 2, 2021.

You asked the Plan to pay for the dental services. You say that you received prior authorization for these services. You also say that you would not have gotten the services if they were not approved first. The Plan denied your request. The Plan says the services you received are not listed as covered. The Plan also says that you signed a financial agreement acknowledging your financial responsibility for services that were 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.

Though the Plan offers a dental benefit in excess of Medicare coverage, the crown, root canal, and unspecified preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown (D2740), root canal (D3310), and unspecified preventive service (D1999) provided on September 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided on February 3, 2021.

You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. CPT code G0480 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on February 3, 2021, and received by the lab on February 22, 2021. Of note, the patient resides in one state and the billing laboratory is located in another; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0480) provided on February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete upper denture (D5110), and a complete lower denture (D5120) provided on September 17, 2021.  You asked the Plan to pay for the dental items. You say that you were advised you needed to take your dentures to an in network provider to be evaluated. You say that you had new dentures made after 2 visits. You also say that the provider should be paid. The Plan denied your request. The Plan says dentures are covered every 3 calendar years. The Plan also says that the frequency limit has been exceeded.  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 dentures are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a complete upper and lower denture that you received on February 26, 2021. Therefore, we decided that the Plan does not have to pay for the complete upper denture (D5110), and a complete lower denture (D5120) provided on September 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine eyewear purchased September 21, 2021, from an out-of-network (OON) provider.  You asked the Plan to pay for the routine eyewear. You say that this eyewear provider is cheaper than network providers and should be covered. The Plan denied your request. The Plan says the routine eyewear is not covered when provided OON.  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 these services when they are obtained from a provider in the Plan's vision vendor network.  We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of the routine eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the routine eyewear purchased September 21, 2021, from an out-of-network (OON) provider.