Persius/hicric huggingface dataset:
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 did not call for the ambulance and you did not want it to come. You say that your family member called for it but there was nothing that needed to be done. You stated that you had just gotten out of the hospital and your new medication had made you disoriented. You say that the responders looked at you and then they left ten minutes later after doing nothing else. 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 March 17, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on January 8, 2020.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 28, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services provided by an out-of-network provider 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 physician's services provided on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on September 16, 2019.
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the submitted code does not appropriately reflect the services provided.
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 99350 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to 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 presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99350 is not supported in the record. Specifically, CPT code 99350 applies to a home visit by a physician of advanced practitioner. The records do not indicate that this service was rendered by a physician or advanced practitioner. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit (99350) provided on September 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Imatinib Mesylate 100mg tablet medication (J8999).
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the
enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered oral cancer drug requested here is not among the types which are
covered by Medicare Part B as it does not have an injectable form. Therefore, we decided that the Plan does not
have to pre-approve the Imatinib Mesylate 100mg tablet medication (J8999).
Benefits for this medication 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 1, 2019 through October 2, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 1, 2019 through October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because
LTACH admission is medically necessary. The Plan denied your request. The Plan says the member's
necessary care may be safely rendered at a lower level.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no evidence that the enrollee requires services that are not currently available.
As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction (92015) provided on February 6, 2020.You asked the Plan to pay forthis service. You say that because Glaucoma was detected during the routine eye examination, the services should be considered urgent in nature and paid for by the Plan.The Plan denied your request. The Plan says you have exceeded the allowable coverage for your routine eye benefit. Additionally, the refraction services were documented as routine, not urgent in nature.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.  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically,the Plan issued payment in the amount of $75 for the routine eye exam provided. You have an allowance of up to $75 per calendar year for a routine vision exam, including refraction.Any amount billed by the provider above the $75 allowance would be your responsibility. Therefore, we decided that the Plan does not have to pay forthe eye refraction (92015) provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. The rules say that no payment is made under Medicare for services authorized by the Veteran's Administration. We looked at the file and Medicare rules. The file shows that the services at issue were Veteran's Administration services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered on December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on January 9, 2019. You asked the Plan to pay for the services. You say that the claim was submitted within the timely filing guideline. 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 claim for the services was not filed until January 14, 2020. 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 for the services provided to the enrollee on January 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy and endoscopy provided
on July 24, 2019.
You asked the Plan to waive the copayment for the colonoscopy and endoscopy. You say that you thought this
was preventive. You say that you don't have this kind of money. 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 $200 for
each in-network, Medicare-covered ambulatory surgical center visit and outpatient hospital facility visit.
You have been asked to pay a $200 copayment for the colonoscopy and endoscopy. The colonoscopy and
endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers" benefit category. The colonoscopy and endoscopy are considered diagnostic
surgical procedures. 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 colonoscopy and endoscopy
provided on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for polishing/resurfacing of ocular prosthesis (V2624) provided on May 17, 2019 by a non-contracted provider.You asked the Plan to waive the deductible for the services. You say that you are appealing your cost-share responsibility for the services you received.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 polishing/resurfacing of ocular prosthesis (V2624) provided on May 17, 2019 by a non-contracted provider. At the time of services rendered you had not met your $750 deductible; therefore, you have been asked to pay $80.29 for the services to apply to your deductible. Your EOC states, polishing/resurfacing of ocular prosthesis (V2624) provided on May 17, 2019 by a non-contracted provider. 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 deductible for polishing/resurfacing of ocular prosthesis (V2624) provided on May 17, 2019 by a non-contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the cerumen removal rendered on December 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 69209 was not billed correctly.
The Plan must follow Medicare rules. The rules say that anatomical modifiers must be reflected in the medical records. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 69209 without a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the cerumen removal rendered on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laser eye surgery provided on January 24, 2020.
You asked the Plan to waive the copayment for laser eye surgery. You say that you were informed you wouldn't be billed for the second treatment. 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 $350 copayment for each Medicare-covered outpatient surgery at an in-network outpatient hospital.
You have been asked to pay a $350 copayment for the laser eye surgery. The laser eye surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan contract states that the copayment applies to each surgery. 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 laser eye surgery provided on January 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided on November 15, 2019.You asked the Plan to waive the copayment forphysical therapy. You say that you received a letter stating services were approved. You say that at no time were you asked to pay a copayment.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 $40 copayment for each in-network, Medicare-covered therapy visit.You have been asked to pay a $40 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation 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 forphysical therapy provided on November 15, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on March 19, 2020.You asked the Plan to waive the copayment for the ER visit. You say that they didn't do anything. You say that you shouldn't have another copayment for this.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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were examined, advised when sutures should be removed and wound care instructions were provided. 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 ER visit provided on March 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 2, 2019 through December 16, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were kept inpatient the additional days by your insurance provider. 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 shows that you were admitted to an in-network provider on December 2, 2019 and discharged on December 16, 2019. You were asked to pay a $290 copayment per day from December 2, 2019 through December 6, 2019, days 1-5 of your inpatient stay. There were no copayment charges from December 7, 2019, day 6 of your inpatient hospital care until your day of discharge December 16, 2019. Per your contract there is a $290 copayment per day required for days 1-5 for in-network 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 pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care from December 2, 2019 through December 16, 2019 provided by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on May 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for lab tests provided on May 28, 2019 by an out of network (OON)provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra IV (J3262).
You asked the Plan to pre-approve the Actemra IV. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Actemra IV. Our reviewer says that the provided medical records do not indicate that the member has tried and failed Remicade or Inflectra. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects. 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 Actemra IV have not been met. Therefore, we decided that the Plan does not have to pre-approve Actemra IV (J3262).