Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from February 4, 2020 to February 27, 2020.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were never told there would be a $30 copayment for each visit. You say you assumed the sessions were being paid by the Plan. 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 $30 copayment for in-network Medicare-covered physical therapy and speech therapy. You have been asked to pay a $30 copayment for each of the physical therapy visits. ($30 x 7 visits = $210). The physical therapy visits fall 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 copayments for the physical therapy visits provided from February 4, 2020 to February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided to the enrollee from February 3, 2019 at 8:17am through February 4, 2019.
You asked the Plan to pay for post stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide 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 to determine if the Plan was correct in denying the request to pay for post stabilization care. Our physician reviewer found the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service Based on the clinical documentation available in the medical record, the patient was stable to transfer by ambulance to an in-network hospital after 8:16 AM February 3, 2019 when the treating cardiologist explicitly documented that the patient was stable for transfer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post stabilization care provided to the enrollee from February 3, 2019 at 8:17am through February 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (78812, 70490 and 71250) provided December 11, 2019.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the procedures were performed as billed.
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 codes 78812, 70490, and 71250 are not supported in the medical record. Specifically, the imaging reports provided in the records do not include a date of service on them to verify the date that the procedures were performed. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (78812, 70490 and 71250) provided December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit and the laboratory test provided on January 8, 2020.
You asked the Plan to waive the coinsurance for the office visit and the laboratory test. You say that you have never been billed this amount from this provider. 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 50% coinsurance for each out-of-network primary care doctor and specialist visit for Medicare-covered benefits (based on the Medicare allowed amount) and 50% coinsurance for out-of-network Medicare-covered outpatient diagnostic tests and therapeutic services and supplies (based on the Medicare allowable amount). You have been asked to pay a total of $99.62 for the office visit and the laboratory test. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the provider is out-of-network. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
January 8, 2020
Office visit
$42.66
50%
$21.33
January 8, 2020
Laboratory test
$78.29
50%
$78.29
Total
$99.62
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 office visit and the laboratory test provided on January 8, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on December 26, 2019.
You asked the Plan to waive the copayment for an ER visit. 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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for an ER visit. An ER visit falls within the emergency care 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 ER visit provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye surgery provided on March 25, 2020.
You asked the Plan to waive the copayment for the eye surgery. You say that the surgery did not take place and you would like the copayment refunded. 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 $325 copayment for outpatient surgery, including services at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $325 copayment for the eye surgery. The eye surgery falls within the "Outpatient surgery, including services at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the eye surgery was completed on March 25, 2020.
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 eye surgery provided on March 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses (V2520) provided December 28, 2019.
You asked the Plan to pay for the contact lenses. You say that the cost of lenses should be reimbursed. The Plan denied your request. The Plan says the maximum benefit has already been exhausted.
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 provides up to $125 per calendar year towards eyewear. We looked at the file and the Plan's rules. The plan applied the $125 allowance towards the $387.96 total. This is the extent of the Plan's eyewear benefit. Therefore we decided the plan does not need to pay any further amount towards the contact lenses provided December 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for kickboxing classes provided from January 9, 2019 to December 31, 2019.
You asked the Plan to reimburse you for the kickboxing classes. You say that the boxing classes help improve your symptoms with Parkinson's Disease. The Plan denied your request. The Plan says the kickboxing classes are not covered under the fitness benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because boxing classes are not a fitness benefit with the Plan. Therefore, we decided that the Plan does not have to reimburse you for kickboxing classes provided from January 9, 2019 to December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass enhanced features, progressive lenses, tint, photochromatic lenses and polycarbonate provided on March 10, 2020.
You asked the Plan to pay for the eyeglass enhanced features. The Plan denied your request. The Plan says enhanced services are not a covered vision benefit with your Plan.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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. The file shows that the Plan does not covered enhanced vision services. Therefore, we decided that the Plan does not have to pay for eyeglass enhanced features, progressive lenses, tint, photochromatic lenses and polycarbonate provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a medical eye exam provided on February
5, 2020.
You asked the Plan to waive the copayment for a medical eye exam. You say that this was a preventative visit
and you should owe a $0 copayment. 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 $45
copayment for medical eye exams.
The medical records show that you received a medical eye exam on February 5, 2020. Therefore, you are
responsible to pay the $45 copayment.
You have been asked to pay a $45 copayment for a medical eye exam. A medical 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 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 a medical eye exam
provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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
physician's services. 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 January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an audiologic function test provided on February 10, 2020.
You asked the Plan to waive the copayment for an audiologic function test. You say that you disagree with the charges because you did not request the test to be done. 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 $45 copayment for hearing services. You have been asked to pay the allowed amount of $36.89, which is less than the $45 copayment for an audiologic function test. An audiologic function test falls within the hearing 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 audiologic function test provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement provided on January 14, 2020.
You asked the Plan to waive the copayment for debridement. You say that you feel that the charges are too high. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $350 copayment for debridement. Debridement 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 debridement provided on January 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624).
You asked the Plan to pre-approve the CardioMEMS device. You say that the CardioMEMS is medically necessary. The Plan denied your request. The Plan says the device is considered investigation in this application at this time.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 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 CardioMEMS device. have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device (33289, C2624).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent syringe.
You asked the Plan to pre-approve Dupixent syringe. You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Dupixent syringe.
Benefits for Dupixent syringe 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit and radiation therapy planning
provided on January 20, 2020 and January 27, 2020.
You asked the Plan to pay for the outpatient office visit and radiation therapy planning. You say that both of
the claims were submitted correctly, and contain the correct modifier to indicate the diagnosis is not related to
Hospice. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of
all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on January 17, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the outpatient office
visit and radiation therapy planning provided on January 20, 2020 and January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The
Plan denied your request. The Plan says that this is non-covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered
because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve
a power seat elevation feature (E2300) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex Faspro.
You asked the Plan to pre-approve Darzalex Faspro. You say that the medication is medically necessary. The
Plan denied your request. The Plan says the drug is not FDA approved when used in conjunction with
Venetoclax.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Darzalex Faspro. Our reviewer says
that the requested drug is not medically necessary. Our physician reviewer found this drug is not approved for
the enrollee's diagnosis when used in combination with Venetoclax.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does
not have to pre-approve Darzalex Faspro.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on January 13, 2020.
You asked the Plan to pay for the hearing aids. You say that your friend went through the Plan's hearing
provider and was not satisfied with the results. You say that you found a better value of hearing aids from the
out-of-network provider. The Plan denied your request. The Plan says you are responsible for paying the full
cost of services that are not covered by our plan, either because they are not plan covered services, or they were
obtained out-of-network and were not authorized.
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 file shows that you obtained the hearing aids from an out-ofnetwork
provider. 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 for hearing aids provided on
January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system or accessory electronic
connection.
You asked the Plan to pre-approve the power seat elevation system (E2300) and accessory electronic
connection (E2310). You say that the enrollee needs a Group 3 power wheelchair, accessories, power seat
elevation system, and accessory electronic connection. The Plan denied your request. The Plan says power seat
elevation systems are not covered by Medicare or the Plan and the electronic connection is not necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. A power seat elevation feature does not serve a purpose that is
primarily medical in nature. The electronic connection is not necessary. Based on this information, we decided
that Medicare rules for coverage of the power seat elevation system (E2300) and accessory electronic
connection (E2310) have not been met. Therefore, we decided that the Plan does not have to pre-approve a
power seat elevation system or accessory electronic connection.