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

We decided that the Plan does not have to pay for the services you received on October 3, 2018, and October 31, 2018.You asked the Plan to pay for the services. You say that you met your maximum out-of-pocket.The Plan denied your request. The Plan says your maximum out-of-pocket was met on October 31, 2018.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 have a $6,700 maximum out-of-pocket per calendar year.Review of the file shows that you were provided services on October 3, 2018, and October 31, 2018. The records show that your maximum out-of-pocket was not met until October 31, 2018. It was not met prior to the services in question being rendered. 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 pay for the services you received on October 3, 2018, and October 31, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided by the out of network provider.
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says the services could have been provided in network. The Plan says the services were not urgent or emergent. The Plan says the services were ordered by a non-participating pain management specialist. the Plan also says that the services were not authorized.
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 provider in this case is not a network provider with the Plan. The Plan has confirmed there are 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 drug testing provided by the out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered to the enrollee.
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 procedure code 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 and 32555. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32555. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses providedon January 30, 2019.You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says routine eyewear is not a covered benefit under your Plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on January 30, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you were attending church and the heat caused you to pass out. You say that someone called an ambulance and by the time it arrived you were conscious. The responders checked your vitals and determined that it was not necessary for you to be transported to the hospital.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 4, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the pneumococcal vaccine you received.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says that this vaccine is covered once per lifetime.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The documentation submitted by the plan does not contain evidence that the requested vaccine is only covered once per lifetime. Medicare rules say that the pneumococcal vaccine is a covered benefit. The plan's contract also does not indicate that this vaccine will only be covered once per lifetime. Without supporting documentation, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the pneumococcal vaccine you received.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on August 6, 2019.
You asked the Plan to pay for the vaccine. You say that you were told that this service was covered. The Plan denied your request. The Plan says this is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on August 6, 2019.
Benefits for the vaccine 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography (76377) provided on July 19, 2019.You asked the Plan to pay for 3D rendering with interpretation and reporting of computed tomography. You say that this service should be reprocessed and paid.The Plan denied your request. The Plan says criteria have not been met for this service.The Plan must follow Medicare rules. Medicare rules say that if a covered secondary diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.We looked at the file and Medicare rules. In this case, the claim was not billed with a covered secondary diagnosis code as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D rendering with interpretation and reporting of computed tomography have not been met.Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography (76377) provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the initial 15 minutes of moderate sedation services. We decided that
the Plan does not have to pay for each additional 15 minutes of moderate sedation (99153).
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration
based on the records submitted. The Plan says that the initial 15 minutes of moderate sedation (99152) is not
supported by the medical record. The Plan also says that CPT code 99153 is a technical component only which
means it is not separately payable when billed with a facility place of service.
We decided that the Plan has to pay for the initial 15 minutes of moderate sedation services.
The Plan follows Medicare rules. Medicare rules say that Medicare allows separate reporting for moderate
conscious sedation (CPT codes 99151-99153) when provided by the same physician performing a medical or
surgical procedure. You can find this information at National Correct Coding Initiative Policy Manual For
Medicare Services Chapter 11.
The file shows that you have an indication for which Medicare will cover moderate sedation 99152. The record
indicates that 25 min of monitored conscious sedation was rendered with the presence of a trained observer.
Therefore, we decided that the Plan has to pay for the moderate sedation services.
We also decided that the Plan does not have to pay for each additional 15 minutes of moderate sedation
(99153).
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
CPT Code 99153 was billed with facility POS 22. Per the 2019 Physician Fee Schedule, CPT Code 99153 has a
Professional/Technical status indicator of 3. This means that payment for 99153 is included in the payment to
the facility. Therefore, we decided that the Plan does not have to pay for moderate sedation (99153).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 7, 2019, and June 10, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 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 services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on May 7, 2019, and June 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient stay provided from March 5, 2019 through March 9, 2019 and the office visits provided on June 18, 2019 and July 3, 2019.
You asked the Plan to waive the copayments for the inpatient stay and office visits. You say that you were not in the hospital on March 9. You say that you received different bills for the same treatments. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day for days 1-5 at an in-network hospital. A $50 copayment for Medicare-covered specialist services. You have been asked to pay $650, which is less than the standard copayment for a 5-day inpatient stay. You have been asked to pay a $50 copayment for the office visit provided on June 18, 2019. You have also been asked to pay $25.73, which is less than the standard $50 copayment for the office visit provided on July 3, 2019.
The inpatient stay falls within the "Inpatient hospital care" benefit category. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were an inpatient for five days. 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 copayments for the inpatient stay provided from March 5, 2019 through March 9, 2019 and the office visits provided on June 18, 2019 and July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe clinic visit provided on July 31, 2019.You asked the Plan to waive the copayment forthe clinicvisit. You say that there was nosurgery. You say that you won't go back to this facility.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment per facility visit.You have been asked to pay a $50 copayment for the clinicvisit. The clinicvisit falls within the "Outpatient hospital services" benefit category. The records show that the clinic visit was for wound 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 pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe clinicvisit provided on July 31, 2019.Your complaint about the poor treatmentis not a valid appeal for medical coverage. This part of yourcomplaint 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) monitoring and analysis provided on August 2, 2019 by the out of network provider.

You asked the Plan to pay for the physician services. You say that the enrollee is refusing to be responsible for an out of network deductible for a device that was given to him by an in network cardiologist. You also say that the heart monitor was provided to the enrollee at the request of the in network provider. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says that the referring provider is not a Plan provider.

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 provider in this case is not a network provider with the Plan. 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 electrocardiogram (EKG) monitoring and analysis provided on August 2, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe medical eye exam provided on August 26, 2019.You asked the Plan to waive the copayment forthe medical eye exam. You say that you should be able to get a free eye check even you have an eye problem. 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 $50 copayment for each in-network Medicare-covered exam to diagnose and treat diseases or conditions of the eye. You have been asked to pay a $50 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows a diagnosis of dry eye syndrome of bilateral lacrimal glands.Therefore, the eye exam is medical in nature.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, wedecided that the Plan does not have to waive the copayment forthe medical eye exam provided by the provider on August 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for vertebral corpectomy (63090) provided on November 7, 2018.You asked the Plan to payfor vertebral corpectomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT 63090 is not supported by the medical record.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 63090 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment.We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pay for vertebral corpectomy. Our reviewer says that CPT code 63090 is not supported. Our reviewer found the record does not contain evidence that a vertebral corpectomy by transperitoneal or retroperitoneal approach was performed during this episode of care.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of vertebral corpectomy have not been met. Therefore, we decided that the Plan does not have to pay for vertebral corpectomy (63090) provided on November 7, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided on September 1, 2019.You asked the Plan to waive the coinsurance for the DME. You say that you are appealing for reconsideration of the denied charges.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 on September 1, 2019. 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 for the DME provided on September 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ALS emergency ambulance service (A0427) and ground mileage (A0425) provided on June 18, 2019.
You asked the Plan to pay for the ambulance service. You say that this claim needs to be reconsidered and the records should support necessity of the services. The Plan denied your request. The Plan says the information provided does not support medical necessity for ambulance transport.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance service. Our reviewer says that the documentation did not support that the ambulance transport was medically reasonable and necessary. Our physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. The enrollee could have been safely transported by an alternate means for medical evaluation. The enrollee's vital signs were stable and there was no documented need for BLS or ALS services. 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 ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the ALS emergency ambulance service (A0427) and ground mileage (A0425) provided on June 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on June 30, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on June 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 2, 2019 to April 4, 2019 by out of network 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 referring provider 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 April 2, 2019 to April 4, 2019 by out of network provider.