Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe DME provided on October 16, 2019 by an in-network provider.You asked the Plan to waive the coinsurance forthe DME. You say that you did not order the supplies and were not aware of any copayments.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME provided on October 16, 2019 by an in-network provider. You are asked to pay 20% coinsurance for the DME.  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 forthe DME provided on October 16, 2019 by an in-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0398, A0425, A0427) provided on November 4, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost share 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 $250 copayment for Ambulance Services. You have been asked to pay a $250 copayment for the ambulance services. The ambulance services fall within the Ambulance 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 an ambulance transport (A0398, A0425, A0427) provided on November 4, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided from November 11 to November 12, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you were inpatient and disagree with the charges. 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received an EGD from November 11, 2019 to November 12, 2019 while under observation. Therefore, you are responsible to pay the $400 copayment. You have been asked to pay a $400 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 EGD provided from November 11, 2019 to November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Life Alert system for the enrollee.You asked the Plan to pre-approvea Life Alert system. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that this is considered a convenience item that is not primarily medical in nature and thus not covered.The Plan must follow Medicare rules. The rules say that telephone alert systems are excluded from coverage as these are emergency communications systems and do not serve a diagnostic or therapeutic purpose.Although this device may be appropriate, it is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approvea Life Alert system for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe medical eye exam and or the ophthalmoscopy provided on October 22, 2019.You asked the Plan to waive the deductible forthe medical eye exam and the ophthalmoscopy. You say that you disagree with this amount. 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. Your contract with the Plan says that there is a $600 deductible that applies towards out-of-network Medicare covered exam and out-of-network Medicare-covered non-radiological diagnostic services. The medical eye exam you asked the Plan to waive the deductible for falls within the "Vision care" benefit category. The ophthalmoscopy you asked to Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $600 deductible that applies towards the medical eye exam and or the ophthalmoscopy. This cost sharing is a contractual obligation that had not been met at the time the medical eye exam and the ophthalmoscopy were received on October 22, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe medical eye exam or the ophthalmoscopy provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural injections (62323).
You asked the Plan to pre-approve lumbar epidural injections. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no imaging of the affected area to correlate with clinical findings.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are covered when the enrollee has failed of four weeks of non-surgical, non-injection care, which includes appropriate oral medications and physical therapy. 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 lumbar epidural injections. Our reviewer says that the requested injections are not indicated at this time. Our physician reviewer found there is no imaging or recent physical therapy documented. Therefore, the request does not meet criteria is considered not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injections (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on September 9, 2019.
You asked the Plan to waive the copayment for the duplex scan. You say that you were not informed about the $100 copayment. 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 $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $100 copayment for the duplex scan. The duplex scan falls within "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 the duplex scan provided by on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and does not have to waive the coinsurance for a Medicare Part B drug injection provided on December 5, 2017.
You asked the Plan to waive the copayment for an office visit and to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with the charges. 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 $20 copayment for services obtained by a specialist. Your contract with the Plan also clearly says that you must pay 10% coinsurance for Medicare Part B prescription drugs. You had an office visit on December 5, 2017. Therefore, you are responsible to pay the $20 copayment. You had a Medicare Part B drug injection on December 5, 2017. The allowed amount is $1,960.28 and 10% of that is $196.03. The total amount you owe is: $216.03. You have been asked to pay the total amount of $216.03 for an office visit and a Medicare Part B drug injection. An office visit and falls within the physician/practitioner services, including doctor's office visits benefit category.
A Medicare Part B drug injection 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 copayment for an office visit and does not have to waive the coinsurance for a Medicare Part B drug injection provided on December 5, 2017.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus.
You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says that tier exceptions only apply to Part D drugs.
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 Tacrolimus.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for needle electromyography services provided to the enrollee on September 9, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 95861-26 (1 Unit) remains not supported.
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 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas." 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 services. Our reviewers says that the services at issue in this case were coded correctly. Our physician reviewer found the documentation indicates that free running EMGs were conducted on the left and the right. Therefore, the billing of CPT 95861 is supported. 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 services have been met. Therefore, we decided that the Plan has to pay for needle electromyography services provided to the enrollee on September 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve 25mg Imipramine tablets.You asked the Plan to pre-approve the Imipramine. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this medication does not fall under Part B coverage.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 25mg Imipramine tablets. Benefits for the Imipramine may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient mental health services (99214) provided November 4, 2019
You asked the Plan to waive the deductible for the outpatient mental health services. You say that the cost sharing should be waived. The Plan denied your request. The Plan says there is a 30% coinsurance once the $1,000 deductible has been met.
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 there is a $1000 deductible for Outpatient Mental Health Services. The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Mental Health Services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for Outpatient Mental Health Services. This cost sharing is a contractual obligation that had not been met at the time the outpatient mental health services was received on November 4, 2019. Therefore, we decided that the Plan does not have to waive the deductible for outpatient mental health services (99214) provided November 4, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 15, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that cost sharing is a contractual obligation under the plan and cannot be waived.
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 $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay less than a $250 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip benefit category. This means that you have been asked to pay less than 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 transport provided on September 15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is unable to fully participate in therapy due to her non-weight-bearing status on the right lower extremity.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensityof service criteria for an inpatient basis in a skilled nursing facility setting.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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe mobile X-ray services (73610, 73630, Q0092, R0070) provided on August 30, 2019.You asked the Plan to pay forthe x-ray services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not preauthorized or emergent.Medicare rules say that plans can require enrolleesto 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 isnot 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 forthese items/services.Therefore, we decided that the Plan does not have to pay forthe mobile X-ray services (73610, 73630, Q0092, R0070) provided on August 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary to get therapy.The Plandenied your request. The Plansaysthis is not medicallynecessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of implantable interstitial glucose sensor (0446T) provided on October 14, 2019.
You asked the Plan to pay for the insertion of implantable interstitial glucose sensor. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that CPT 0446T is not covered. We looked at the file and Medicare rules. The service at issue is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the insertion of implantable interstitial glucose sensor have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of implantable interstitial glucose sensor (0446T) provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 27, 2019.
You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says there was no authorization to purchase the hearing aids from a non-contract provider.
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. 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 did not pre-approve the hearing aids. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided by on August 27, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided from September 6, 2019 to November 1, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says you must choose in-network providers for care.Medicare rules say that plans can require enrollees to get care from network providers. Thecontract 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided from September 6, 2019 to November 1, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B injection provided on October 15, 2019.You asked the Plan to waive the coinsurance forthe Part B injection. You say that you were told everything would be picked up with Medicare and insurance. 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 20% of the total cost for Medicare B chemotherapy drugs and for other Medicare Part B drugs. You have been asked to pay $231.31 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,156.55. ($1,156.55 x 20% = $231.31). The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have beenasked 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 forthe Part B injection provided on October 15, 2019.