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

We decided that the Plan does not have to pay for the cervical cancer screening rendered to you on September 5, 2019.
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 you have exceeded the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that a cervical cancer screening is covered once every two years. We looked at the file and Medicare rules. The file shows that you previously had a cervical cancer screening on June 10, 2019 for which the Plan approved and paid. The screening on September 5, 2019 was performed fewer than 24 months from your previously covered screening. Therefore, we decided that the Plan does not have to pay for the cervical cancer screening rendered to you on September 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on August 9, 2019.You asked the Plan to pay for the hearing aids. You say that it was not made clear to you that you needed to purchase the hearing aids from an in-network supplier. Hearing aids have become an important instrument in your quality of life.The Plan denied your request. The Plan says hearing aids purchased from out of network providers are not covered.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. You may choose to order hearing aids through other providers. The health plan contract says that hearing aids must be purchased from other providers.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for hearing aids purchased on August 9, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDiclofenac Sodium 1% gel for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered by the Plan.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-approveDiclofenac Sodium 1% gel for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe 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 pay for the medical services provided on October 31, 2019 by an out of network (OON) provider.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 the services were rendered by a non-participating 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, outof area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 forthe medical services provided on October 31, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered  on September 10, 2019.
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 the services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC. We looked at the file and Medicare rules. The file shows that procedure code 86334 was billed with the -26 modifier. There is no documentation to support that the PC was performed in a different payment locality than the TC; therefore, separate payment of the PC is not allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 1, 2019 to August 2, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the enrollee was appropriately admitted to inpatient status as she presented with increasing shortness of breath and increased use of home oxygen. The admitting physician based his decision to admit on the patient's presenting symptoms, findings, assessment and treatment plan.The Plan denied your request. The Plan says the criteria for inpatient admission were not met per Medicare Guidelines. The member's condition could have been managed at alower level of care.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment were met in this case. Our physician reviewer found the enrollee presented to the emergency department (ED) on August 1, 2019 with shortness of breath. The evaluation revealed stable vital signs, and the physical exam was notable for wheezingon chest exam. She was treated with oxygen, intravenous (IV)fluids, and nebulizer treatments. She was admitted and evaluated by Cardiology. On August 2, 2019, a nuclear stress test and an echocardiogram were administered. Her condition improved with IV fluids and she was discharged home on August 2, 2019, on an increased dose of oral Lasix with scheduled follow-up. The review indicates that the enrollee was stable and appropriate for observation level of care services after the emergency room evaluation on August 1, 2019. The review has determined that it was not reasonable for the admitting to expect that the enrollee's necessary hospital stay would likely span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided August 1, 2019 to August 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwenty-four (24) additional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you need additional routine transportation trips.The Plan denied your request. The Plan says that you have exceeded your benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-four (24) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of additional routine transportation trips.Therefore, we decided that the Plan does not have to pre-approvetwenty-four (24) additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient consultation (99254) provided on March 21, 2019.
You asked the Plan to pay for the inpatient consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says code 99254 is assigned a status code of I.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99254 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule, CPT code 99254 has a status code of I. This means that 99254 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for inpatient consultation (99254) provided on March 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lantus for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that the request is not a covered benefit under the enrollee's plan because Lantus is a drug the enrollee gives to himself.
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 Lantus for the enrollee.
Benefits for this drug 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound of the eye provided on October 2, 2019.You asked the Plan to waive the copayment forthe ocular ultrasound. You say that the pre-surgery testing should be included in your cataract surgery copayments. The Plan denied your request. The Plan says you have been charged the correct cost-sharingamount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for diagnostic procedures and tests in an in-network specialist's office.You have been asked to pay a $35 copayment for the ocular ultrasound. The ocular ultrasound 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 forthe ultrasound of the eye provided on October 2, 2019.Your complaint about the provider balance billing 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe psychiatric diagnostic evaluation provided on August 1, 2019.You asked the Plan to waive the deductible forthe psychiatric diagnostic evaluation. You say that you are being double billed. You say that you cannot pay for this.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your in-network deductible is $250, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will payour share for your covered in-network medical services. Outpatient mental health care is not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient mental health care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $250 in-network deductible applies to outpatient mental health care. This cost sharing is a contractual obligation that had not been met at the time the psychiatric diagnostic evaluation was received on August 1, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe psychiatric diagnostic evaluation provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 24, 2019 by an out of network (OON) provider.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 the services were rendered by a non-contracted 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 the medical services provided on September 24, 2019 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz XR for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that Medicare Part B does not cover drugs that are usually self-administered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeljanz XR for the enrollee.
Benefits for this drug 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 pay forthe train of four testing (CPT 95999) provided to the enrollee on January 11, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan saysthis service is considered a bundled procedure.The Plan must follow Medicare rules. Medicare rules say that all services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code.We looked at the file and Medicare rules. The requested train of four testing is a bundled service. This testing is considered integral to accomplishing the procedure in question and therefore is considered a component part of the comprehensive code. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe train of four testing (CPT 95999) provided to the enrollee on January 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe EKG provided on October 2, 2019.You asked the Plan to waive the copayment forthe EKG. You say that you have never paid for an EKG before and you have one every year. 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 $10 copayment per day for Medicare-covered tests. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $10 copayment for the EKG.You have been asked to pay a $8.94 copayment for the EKG. The 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 
forthe EKG provided on October 2, 2019.Our decision is only about the October 2, 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital services rendered to you from June 8, 2018 to June 10, 2018.You asked the Plan to waive the copayment forthese services. You say that you had no option but to go to the hospital in Rhode Island.The Plan denied your request. The Plan says the copayment 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 $360 copayment per day for days 1-5 for each inpatient admission. Review of the file shows that you received two days of inpatient hospital services from June 8, 2018 to June 10, 2018. You were not assessed a copayment for your date of discharge on June 10, 2018. You have been asked to pay a $360 copayment per day for these services, for a total of $720. These services fall within the inpatient admission 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 forthe inpatient hospital services rendered to you from June 8, 2018 to June 10, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Orthovisc for the enrollee.You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says that Medicare rules say that Part B drugs are not allowed to be moved to a lower cost level.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Orthovisc for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forBotox injection services (CPT 64612) provided to the enrollee on September 18, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere is a missing/incomplete/invalid diagnosis or condition.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, theCPT Code Manual definition of code 64612 is "Chemodenervation of muscle(s)."We find that CPT code 64612 is not supported in the medical record. Specifically, this code was billed with two diagnosis codes -R25.1 and G24.4 -that cannot be billed together. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forBotox injection services (CPT 64612) provided to the enrollee on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership provided from January 17, 2018 to September 17, 2018.You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says the claim was filed after the time limit.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 the claim was filed beyond the time limit. Therefore, we decided that the Plan does not have to reimburse you for a gym membership provided from January17, 2018 to September17, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Low Dose Computed Tomography (LDCT) Lung
Cancer Screening.
You asked the Plan to pre-approve the LDCT Lung Cancer Screening. You say that the screening is medically
necessary. The Plan denied your request. The Plan says rules for coverage have not been met in this case.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 LDCT Lung Cancer Screening. Our
reviewer says that coverage criteria has not been met. Our physician reviewer found the record shows that the
enrollee is outside the age range that is approved to receive the LDCT Lung Cancer Screening. Rules for
coverage require the enrollee be between 55 and 77 years of age.
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 LDCT Lung Cancer Screening have not been met. Therefore, we decided
that the Plan does not have to pre-approve Low Dose Computed Tomography (LDCT) Lung Cancer Screening.