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

We decided that the Plan does not have to reduce the coinsurance for the outpatient knee surgery you had on March 5, 2021.
You asked the Plan to reduce the coinsurance for the outpatient knee surgery. You say that you were an inpatient and should only have the inpatient copayment. You said that you were in the hospital overnight. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that there was no order from your doctor or the hospital to admit you as an inpatient.
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 outpatient surgery.
You have been asked to pay 20% coinsurance for the outpatient knee surgery. The knee surgery falls within the outpatient surgery benefit category because your doctor did not write an order to admit you to the hospital. 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 coinsurance for the outpatient knee surgery you had on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on August 4, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on August 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagoduodenoscopy (upper GI endoscopy) and diagnostic colonoscopy you had at an outpatient hospital facility on January 11, 2011.
You asked the Plan to waive the copayment for the upper GI endoscopy and diagnostic colonoscopy. You say that this was a screening colonoscopy and your last one was five years ago. 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 $275 copayment for outpatient surgery at an outpatient hospital facility. Records show that these procedures were performed because of epigastric pain and a history of polyps. The colonoscopy was not ordered as a screening test and the upper GI endoscopy is always considered an outpatient
surgical procedure. That is why the outpatient surgery copayment applies. 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 esophagoduodenoscopy (upper GI endoscopy) and diagnostic colonoscopy you had at an outpatient hospital facility on January 11, 2011.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Oncotype DX Genomic Prostate Score testing provided
on February 23, 2021.
You asked the Plan to pay for the Oncotype DX Genomic Prostate Score testing. You say that the Oncotype
DX Genomic Prostate Score testing provided was medically necessary. The Plan denied your request. The Plan
says the Oncotype DX Genomic Prostate Score testing provided was not medically necessary.
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 pay for the Oncotype DX Genomic Prostate Score testing. Our reviewer says that the Oncotype DX Genomic Prostate Score testing provided was not medically necessary. Our physician reviewer found the enrollee is diagnosed with T2c and grade group 2. This is unfavorable intermediate risk. Per NCCN guidelines, prostate ca 2.2021 page MS65, Oncotype DX is not approvable for unfavorable intermediate risk, only favorable intermediate risk and better. 
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 Oncotype DX Genomic Prostate Score testing have not been met. Therefore, we decided that the Plan does not have to pay for the Oncotype DX Genomic Prostate Score testing provided on February 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for physical and occupational therapy.
You asked the Plan to pre-approve the referral. You say that there is an exclusive contract with the assisted living home. The Plan denied your request. The Plan says the provided documentation does not demonstrate that you are unable to receive the same services in the community.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for physical and occupational therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had at a lung and allergy specialist's office on April 14, 2021.
You asked the Plan to waive the copayment for the specialist visit. You say that you receive an allergy shot from this provider and it is usually free. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says you are not being charged a copayment for the allergy shot but for the office visit.
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 $15 copayment for visits with a specialist.
You have been asked to pay a $15 copayment for the specialist visit. the specialist visit falls within the visits with a specialist benefit category. his 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 visit you had at a lung and allergy specialist's office on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 8, 2021 by a non-participating 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, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The referring provider 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 the laboratory services provided on April 8, 2021 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the eyewear provided on February 12, 2021.
You asked the Plan to reimburse you for the eyewear. You say that short glasses are supposed to be covered by Medicare or your insurance. The Plan denied your request. The Plan says your Plan does not have a supplemental vision benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine eyewear. The services you asked the Plan to reimburse you for are considered routine eyewear. Therefore, we decided that the Plan does not have to reimburse you for the eyewear provided on February 12, 2021.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for the emergency room (ER) visit you had on January 30, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that this copayment should be waived because you were admitted to the hospital. The Plan denied your request. The Plan says that you were charged this copayment correctly. The Plan says that because you were transferred to a different facility for your hospital admission, the copayment applies.
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 enrollees pay a $120 copayment for emergency room visits. However, the contract also says that this copayment is waived if you are admitted to the hospital within one day for the same condition. The Plan says you must pay a $120 copayment for the ER visit. The records show that you were discharged from the ER and transferred to another hospital to be admitted. Your contract says that the ER copayment is waived if you are admitted. Nowhere in your contract does it say that the admission needs to be at the same facility as the ER visit. Because the contract is silent on this fact, we find that the Plan did not adequately disclose your cost sharing obligation to you. Therefore, we decided that the Plan has to waive the copayment for the emergency room (ER) visit you had on January 30, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015) provided April 7, 2021.
You asked the Plan to pay for the vision services. You say that you was not aware that this is not covered. You cannot afford to pay for this. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
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 Refraction is not covered under the plan benefits. We looked at the file and the Plan's rules. Refraction is not covered under the plan benefits. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for determination of refractive state (92015) provided April 7, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 12, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not 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 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 physician services provided on August 12, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a cardiology nurse practitioner on March 25, 2021.
You asked the Plan to waive the copayment for the visit with a cardiology nurse practitioner. You say that you do not feel you should pay a copayment when you only saw a nurse practitioner. 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 $10 copayment for specialty care with a physician or practitioner. You have been asked to pay a $10 copayment for the visit with a cardiology nurse practitioner. Your contract says that the specialist copayment also applies to practitioner services. 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 visit you had with a cardiology nurse practitioner on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on November 3, 2020.
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99223 is not supported in the medical record. Specifically, this code is considered part of the global surgical package of minor procedure code 10060 (incision and drainage of abscess) which was billed on the same date of service. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on November 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on April 19, 2021.
You asked the Plan to waive the copayment for the lab services. You say that this copayment should be waived because these lab services were part of your annual physical exam. 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 $10 copayment for lab services.
Your Evidence of Coverage says that the annual physical exam only includes a bodily systems exam, measurement and recording of vital signs, a complete medication review, and a review of recent hospitalizations. It does not include lab services. You have been asked to pay a $10 copayment for the lab services. 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 lab services you had on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Prolia injection you received on
December 9, 2020.
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you feel as though Medicare
would have covered this in full. The Plan denied your request. The Plan says you were charged this
coinsurance 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 Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the
Medicare Part B 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 Prolia injection you received on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third facet block injection.
You asked the Plan to pre-approve a third facet block injection. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are
allowed per session per spine region. The need for a three or four-level procedure bilaterally may be considered
under unique circumstances and with sufficient documentation of medical necessity on appeal.
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 a third facet block injection. Our
reviewer says that the services are not medically necessary. Our physician reviewer found only two levels here
are medically reasonable and necessary. The need for a third level is not clearly documented.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a third facet block injection have not been met. Therefore, we decided that the
Plan does not have to pre-approve a third facet block injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for exercise equipment provided on February 9, 2021.
You asked the Plan to reimburse you for the exercise equipment. You say that you called the Plan on
February 21, 2021 and you were told that exercise equipment is covered under the Wellness Allowance benefit. The Plan denied your request. The Plan says per the temporary COVID-19 policy, you could have used your Wellness Allowance towards the purchase of exercise equipment that you can use at home. This change was in
effect from October 1 -December 31, 2020. Since your purchase was made outside of this timeframe, we are unable to approve your request.
The Plan contact says that the Plan covers a supplemental Wellness Allowance benefit.
The Plan's rules for coverage of the Wellness Allowance benefits have not been met because Wellness Allowance benefit, under the temporary COVID-19 policy, could have been used toward the purchase of exercise equipment used at home effective October 1, 2020, through December 31, 2020. The exercise equipment was purchased outside of this timeframe. Therefore, we decided that the Plan does not have to reimburse you for exercise equipment provided on February 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 18, 2021.
You asked the Plan to pay for the services provided. You say that you did not feel comfortable using a network provider. The Plan denied your request. The Plan says the claim processed 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 file shows that you received dental services from an out-of-network provider. We looked at the file, and Medicare rules. Your plan says you pay 100% of the cost for out-of-network services. Based on this information, we decided that the Plan's rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on March 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility), provided on March 31, 2021.
You asked the Plan to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility). You say that you were unaware of the ambulance benefit requirements. The Plan denied your request. The Plan says the additional ambulance transportation mileage is not a covered service because a closer facility was able to meet your needs.
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers ambulance transportation to the nearest appropriate facility. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) have not been met. Specifically, the record shows that you received transportation services beyond the nearest appropriate facility. This means that the additional ambulance mileage is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on March 31, 2021.