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

We decided that the Plan does not have to waive the coinsurance forthe Rituxan provided on August 30, 2019.You asked the Plan to waive the coinsurance forthe Rituxan. You say that in your previous experiences with biologic medications the costs were completely covered by your insurance.The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for the Rituxan. The Rituxan fallswithin 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 forthe Rituxan provided on August 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for Air Ambulance services provided on June 21, 2019.You asked the Plan to pay forthe air ambulance services. You say that the air ambulance service was medically necessary.The Plan denied your request. The Plan says coverage criteria was not met since the enrollee was not transported to the closest appropriate facility.The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services. Our reviewer says that coverage criteria has not been met for the air ambulance services. Our physician reviewer found there is no evidence that the enrollee was in need of services that were not available at the sending facility. The enrollee was not taken to the closest appropriate facility, having bypassed multiple appropriate facilities in the southeastern United States to return to Tennessee.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 air ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forAir Ambulance services provided on June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora duplex scan provided by "the doctor" on September 26, 2019.You asked the Plan to waive the copayment forduplex scan. You say that you did not see this physician and should not have to pay a copayment for this scan.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $10 copayment for duplex scan. You have been asked to pay $10 copayment for duplex scan. Duplex scan 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 fora duplex scan provided by "the doctor" on September 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe post stabilization services provided from May 13, 2019 to May 16, 2019.You asked the Plan to pay forthe post stabilization services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not medically necessary.The Plan must follow Medicare rules, which say that emergency care is covered. Plans mustprovide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pay for the post stabilization services. Our reviewer says that the documentation does not support that the post stabilization services provided were medically reasonable or necessary. Our physician reviewer found the enrollee arrived by ambulance with complaints of feeling faint. The enrollee was diagnosed with a gastrointestinal bleed, anemia on blood thinners, and syncope. An EGD was performed and was negative for any evidence of a bleeding source. The enrollee received blood transfusions and was stabilized. As of after 12:56pm on 5/15/19 the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient level of care services. Therefore, the services rendered are not medically necessary.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 post stabilization services have not been met.Therefore, we decided that the Plan does not have to pay forthe post stabilization services provided from May 13, 2019 to May 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT code 0376T provided on September 12, 2019.You asked the Plan to pay forCPT code 0376T. You say that you would like theplan to reconsider their denial of payment.The Plan denied your request. The Plan says this CPT code is considered not medically necessary by Medicare. The Plan states you are not responsible for paying for this service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare specifically excludes coverage of CPT code 0376T as not medically necessary. Medicare rules state that billing CPT code 0376T inaddition to CPT code 0191T is inappropriate. The file shows that an eye stent was placed under code 0191T and these services were covered under your benefit. Only the additional code, 0376T is not payable. Based on this information, we decided that Medicare rules for coverage of CPT code 0376T have not been met.Therefore, we decided that the Plan does not have to pay forCPT code 0376T provided on September 12, 2019.Please note that you are not responsible for payment of CPT code 0376T.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fordiagnostic testing (95913, 95887, 95886, 95912, and 93922) provided by "the doctor" from May 24, 2019 to June 6, 2019.You asked the Plan to waive the coinsurance forout-of-network diagnostic testing. You say that you did not choose where these tests were done and should not be charged.The Plan denied your request. The Plan says these services processed 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 50% coinsurance for out-of-network diagnostic procedures and tests. You have been asked to pay a 50% coinsurance for out-of-network diagnostic testing. This meansthat 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 fordiagnostic testing (95913, 95887, 95886, 95912, and 93922) provided by "the doctor" from May 24, 2019 to June 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forexternal mobile cardiovascular telemetry with electrocardiographic recording (CPT Code 93229) provided on April 15, 2019.You asked the Plan to waive the coinsurance forthe services. You say that your heart doctor gave you a heart monitor to wear of one week and discovered it was not working. You state you had to have several monitors and cords sent from the provider as they did not work properly.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). You are responsible for a coinsurance per the plan's benefits for outpatient diagnostic services. The cost share was applied correctly per your benefit and is calculated by taking the Medicare-allowed amount and multiplying it by 20%. In this case, the $660.59 Medicare-Allowed x 20% -$0 Sequestration = $132.12. 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 forexternal mobile cardiovascular telemetry with electrocardiographic recording (CPT Code 93229) provided on April 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe foot orthotics provided to the enrollee on August 14, 2018.You asked the Plan to pay forthe DME. You say that the proof of delivery for the DME item was filed incorrectly.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a clean claim for the DME was not filed until September 4, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe foot orthotics provided to the enrollee on August 14, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Diagnostic digital breast tomosynthesis (77061) provided July 29, 2019.You asked the Plan to pay forthe Diagnostic digital breast tomosynthesis. You say that the service was medically necessary.The Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.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 77061 is not supported in the medical record. Specifically, Per the 2019 Year National Physician Fee Schedule Relative Value File July Release, procedure code 77061 has a status code of I which is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the Diagnostic digital breast tomosynthesis have not been met.Therefore, we decided that the Plan does not have to pay fora Diagnostic digital breast tomosynthesis (77061) provided July 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora routine Electrocardiogram (93000) provided on July 24, 2019by the out of network provider. You asked the Plan to pay forthe routine Electrocardiogram. You say that the service was medically necessary.The Plan denied your request. The Plan says the plan has providers that could render the service at issue. The enrollee has no out-of-network benefits and the service was not emergent.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 providethe 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 fora routine Electrocardiogram (93000) provided on July 24, 2019 by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Screening Mammogram (77067) provided September 9, 2019.You asked the Plan to pay forthe mammogram. You say that the mammogram was medically necessary.The Plan denied your request. The Plan says only one screening mammogram can be covered annually per the EOC and Medicare rules.The Plan must follow Medicare rules. Medicare rules say that one screening mammogram is covered after at least 11 months have passed following the month in which the last screening mammography was performed.We looked at the file and Medicare rules. The enrollee already had a screening mammogram on December 3, 2018. The benefit limit for screening mammograms was exhausted at the time this service was rendered. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met.Therefore, we decided that the Plan does not have to pay fora Screening Mammogram (77067) provided September 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe contact lens exam and fitting fee provided on September 4, 2019.You asked the Plan topay forthe contact lens exam and fitting fee. You say that you feel you should not be responsible for this amount.The Plan denied your request. The Plan says the services have been processed correctly per your 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 up to $175 toward eyeglass lenses, eyeglass frames, and contacts. 
We looked at the file and the Plan's rules. Your contact with the plan specifically states that the $175 allowance cannot be used toward the fitting or dispensing of contact lenses. Based on this information, we decided that the Plan's rules for coverage of the contact lens exam and fitting fee have not been met. Therefore, we decided that the Plan does not have to pay forthe contact lens exam and fitting fee provided on September 4, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services provided January 3, 2019 to May 16, 2019.You asked the Plan to pay forthe outpatient mental health services. You say that the services were covered under a previous plan.The Plan denied your request. The Plan says is a type of provider that cannot be paid by Medicare Advantage plans under Medicare rules.The Plan must follow Medicare rules. Medicare rules say that Marriage and Family Therapists (MFT's) are not eligible for reimbursement by the Medicare program.We looked at the file and Medicare rules.The physician is a Marriage and Family Therapist and is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay foroutpatient mental health services provided January 3, 2019 to May 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have to pay forroutine foot care services received on May 8, 2019.You asked the Planto pay forthe services. You say that the services helped prevent surgery.The Plandenied your request. The Plansaysthese services are statutorily excluded from coverage.The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. 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 forroutine foot care services received on May 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care providedon June 4, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were discharged the same day as your surgery, so you do not feel like you should have pay your inpatient copayment.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). Based on our review of the medical record, it states;that you were admitted on June 4, 2019 at 6:30 AM and discharged on June 4, 2019at 3:34 PM. Per the CMS, Medicare Benefit Policy Manual, Chapter 1, Section 10, it states; Aninpatient is a person who hasbeen admitted to a hospital for bed occupancy forpurposes of receiving inpatient hospital services (see 10.2 below). Generally, a patient is considered an inpatient ifformally admitted as inpatient with the expectation that he or shewill require hospital care that is expected tospan at least two midnights and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight. Also, Chapter 12, 30.6.9.1, of the Medicare Claims Processing Manual, it states when a patient has been admitted to inpatient hospital care for a minimum of 8 hours but less than 24 hours and discharged on the same calendar day, observation or inpatient hospital care services (including admission and discharge services) shall be reported. Therefore, you are asked to pay a $335 copayment for one (1) day of inpatient hospital care. 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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided on June 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran eye examination provided by "the doctor" on September 12, 2019.You asked the Plan to waive the copayment foreye exam. You say that you had no injuries or treatment to your eyes except for an examination.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $35 copayment for eye exam. The record shows that this visit addressed multiple non-routine conditions, therefore it is considered to be a diagnostic eye exam and not a routine eye exam.You have been asked to pay $35 copayment for eye exam. Eye exam falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract withthe 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 foran eye examination provided by"the doctor" September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on October 23, 2017.You asked the Plan to pay forthe services. You say that the claim was denied for the referring provider and you submitted a corrected claim with the corrected procedure and the authorization number; however, you submitted an appeal with filingproof which was denied for untimely.The Plan denied your request. The Plan says the claim was denied for untimely filing.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until July 11, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on October 23, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on August 15, 2019.You asked the Plan to waive the copaymentforcardiology visit. You say that the enrollee saw the Physician Assistant at this visit, and this visit was within the 10-day post-operative period for a procedure.The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $40 copayment for cardiology office visit. The enrollee has been asked to pay $40 copayment for cardiology visit. Cardiology visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran office visit provided on August 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids purchased on March 21, 2019.You asked the Plan to pay forthe hearing aids. You say that you needed the hearing aids and you think it is terrible that you can't get anything back of what you paid for.The Plan denied your request. The Plan says this service is not covered when provided by an out of network provider. Hearing aids must be purchased through a plan.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. The Plan pays for hearing aids only when purchased. 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 forhearing aids purchased on March 21, 2019.