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

We decided that the Plan does not have to pay for the breast ultrasound (76641) provided July 13, 2021.
You asked the Plan to pay for the ultrasound. You say that the enrollee had multiple exams on this date of service. Please reconsider for processing. The Plan denied your request. The Plan says the records do not support the service 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, the CPT Code Manual definition of code 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete). We find that CPT code 76641 is not supported in the medical record. Specifically, the records show that 76641-26-LT has been allowed and paid to this provider under another claim. The records provided do not support a second ultrasound of the left breast. The records show the Plan made multiple attempts to obtain additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the breast ultrasound (76641) provided July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an out-of-network provider on April 11, 2021, to April 14, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told by the Plan and the hospital that the Plan had paid for your whole visit. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $400 copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $400 copayment per day for days 1-4 for an inpatient hospital stay.
The total amount you are being asked to pay is $1,200 ($400 x 3 days = $1,200) An inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided by an out-of-network provider on April 11, 2021, to April 14, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on June 23, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you also have Medicaid and feel that your copayments should be fully covered. You want to know if you are on the best Plan for your needs. 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 $90 copayment for emergency care. You received emergency care on June 23, 2021. The record shows that you only qualify for Medicaid to cover your Medicare Part B premiums only. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on January 4, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on January 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided June 10, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. We looked at the file and Medicare rules. The service billed is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81455) provided June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two crowns (D2740 x2) provided on May 24, 2021.
You asked the Plan to pay for the crowns. You say that you would like the Plan to void the charges of $999 and refund you $1,194.20 that you paid to them for a tooth that was wrong executed. The Plan denied your request. The Plan says this claim was processed according to the Plan's negotiated rate. The Plan also says that they are unable to void a claim on services that were actually rendered.
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 responsible for a 70% coinsurance for each crown rendered in-network. The Plan contacted the treating provider's office showing that your responsibility for these services is $999.60. The Plan says that the provider was unable to advise that they are refunding you back but said that the office manager would be auditing your account to determine the refund amount. This treating provider is in-network and signed a contract with the Plan which shows it is against the Plan's contract for this provider to bill you for more than your cost-share amount. Therefore, we decided that the Plan does not have to pay for the two crowns (D2740 x2) provided on May 24, 2021.
Your complaint about the professionalism of and issues you had with the staff and dentist assigned to you 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on August 25, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you should not be responsible for the copayment since the staff did nothing for you. 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 $90 copayment for each emergency room visit. 

You have been asked to pay a $90 copayment for the ER visit. ER visits fall within the Emergency Care 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 emergency room (ER) visit provided on August 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0429) provided on May 27, 2021.

You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that this claim has been denied in error. You also say that the enrollee was admitted to hospice on this date of service, but not until after their transport. 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 enrollee's terminal condition.

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 was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and emergency ambulance transportation (A0429) provided on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for occupational therapy provided on July 7, 2021.

You asked the Plan to reduce the copayment for occupational therapy. You say that you were charged out-of-network when the provider is in-network. You say that you should have been charged the $30 in-network copayment. The Plan denied your request. The Plan says the copayment applied 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 $55 copayment for Medicare-covered occupational therapy visits from an out-of-network provider.

You have been asked to pay a $55 copayment for the occupational therapy visit. Occupational therapy falls within the "Outpatient rehabilitation services" benefit category. The records show the provider is out-of-network. 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 reduce the copayment for occupational therapy provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oral exam (D0120) and prophylaxis (D1110) provided on May 18, 2020.

You asked the Plan to reimburse you for the dental services. You say that the services were denied for timely filing. You say that you sent the letter the same day you received the services. You also say that you sent another letter in July 2021 as you had not yet received reimbursement for the services. The Plan denied your request. The Plan says 1 oral exam is covered per calendar year. The Plan says that 1 prophylaxis is covered per calendar year. The Plan says that the frequency limits for these services have been exceeded. The Plan also says that payment was made for these services that you received on November 11, 2020.

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 frequency limits have been exceeded. Therefore, we decided that the Plan does not have to reimburse you for the oral exam (D0120) and prophylaxis (D1110) provided on May 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service (A0429), provided on September 23, 2021.
You asked the Plan to waive the copayment for the ambulance service. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied 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 $225 copayment for ambulance service. You have been asked to pay a $225 copayment for the ambulance service. This service falls within the ambulance service 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 the ambulance service (A0429), provided on September 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the prophylaxis (D1110) provided on June 2, 2021, by the out of network dentist.

You asked the Plan to waive the out of network cost share for the dental service. You say that you would not have gone to this dentist had you known there would be out of pocket costs. You say that you are on a fixed limited income. The Plan denied your request. The Plan says the plan pays according to a maximum allowable fee schedule when you receive services out of network. The Plan says you are responsible for all the fees in excess of this amount from the billed amount.

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 prophylaxis is listed as covered, out of network providers may bill you for any amount greater than what the plan pays the provider. Therefore, we decided that the Plan does not have to waive the out of network cost share for the prophylaxis (D1110) provided on June 2, 2021, by the out of network dentist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug injections and chemotherapy, provided on February 25, 2021.

You asked the Plan to waive the coinsurance for the Part B drug injections and chemotherapy. You say that there should not be any cost share. The Plan denied your request. The Plan says the cost share was applied 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 20% coinsurance for Medicare Part B prescription drugs. 

You have been asked to pay a 20% coinsurance for the Part B drug injections and chemotherapy. This service falls within the Medicare Part B prescription drugs 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 Part B drug injections and chemotherapy, provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits rendered on July 23, 2021 and August 27, 2021.
You asked the Plan to waive the copayments for these services. You say that the services should be covered with $0 member responsibility. The Plan denied your request. The Plan says the copayments were applied 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 specialist's office services.
Review of the file shows that you had specialist visits on July 23, 2021 and August 27, 2021. You have been asked to pay a $45 copayment per date of service for these services, for a total of $90. These services fall within the specialist's office 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.
The file shows that you had a right ureteroscopy on July 20, 2021. This procedure has a 0-day global surgical period, meaning follow-up services are not included in the original surgery. Therefore, we decided that the Plan does not have to waive the copayments for the specialist office visits rendered on July 23, 2021 and August 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging,
tomographic (78452) provided on June 9, 2021.
You asked the Plan to waive the copayment for myocardial perfusion imaging, tomographic. You say that you
have never been charged a copayment before nor were you informed about a copayment. The Plan denied your
request. The Plan says the correct copayment was applied.
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 $150
copayment for each visit for the following Medicare-covered diagnostic radiology services: computed
tomography, magnetic resonance, and nuclear medicine studies.
You have been asked to pay a $150 copayment for myocardial perfusion imaging, tomographic. Myocardial
perfusion imaging, tomographic 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 myocardial perfusion
imaging, tomographic (78452) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on July 19, 2021.

You asked the Plan to pay for ophthalmological services. The Plan denied your request. The Plan says that the Plan does not process out of network claims nor reimburse members for services rendered out of network.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on July 19, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an esophagogastroduodenoscopy (EGD)
(43239), provided on August 31, 2021.
You asked the Plan to waive the copayment for an EGD. You say that the service was medically necessary. The
Plan denied your request. The Plan says the cost share was applied 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 $325
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $325 copayment for an EGD. an EGD 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 an esophagogastroduodenoscopy (EGD) (43239), provided on August 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 12, 2021.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you kept the dental rider until July 31 when it was cancelled, and later went for your 6-month checkup and cleaning which should have been covered. You also say that it was your understanding that with the regular dental plan, it covers two cleanings per year and the rider is extra for work to be done. The Plan denied your request. The Plan says you had a $500 annual maximum which was utilized in your past two visits on February 10, 2021, and March 10, 2021, claims totaling $629, which is over the $500 maximum and why the August 12, 2021 claim denied for $139.00. The Plan also says that though these services are covered benefits in your dental plan, you had already reached your annual maximum of $500.00.

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 $500 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 March 10, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 12, 2021.