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

 
We decided that the Plan does not have to waive the coinsurance for the medical services you received from an 
out-of-network primary care doctor from December 2, 2019, to December 18, 2019. 
 
You asked the Plan to waive the coinsurance for the out-of-network services. You say that you thought this 
provider was in-network with your Plan. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 50% of 
the total cost for primary care services with an out-of-network provider.  
 
You have been asked to pay 50% of the total cost for the out-of-network services. We have confirmed that the 
provider of these services is an out-of-network provider with your specific Plan. 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 medical services you received from an out-of-network primary care doctor 
from December 2, 2019, to December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for 2 inpatient hospital stays at an out-of-
network hospital on January 27 to February 2, 2020, and on February 5 to February 11, 2020. 
 
You asked the Plan to waive the coinsurance for 2 inpatient hospital stays at an out-of-network hospital. You 
say that you had no idea and were not told that the hospital was an out-of-network provider. The Plan denied 
your request. The Plan says the correct coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each inpatient admission to an out-of-network hospital.  
 
You have been asked to pay $3,870.31, or 20% coinsurance of the Plan-allowed amount of $19,351.56, for an 
inpatient hospital stay at an out-of-network hospital on January 27 to February 2, 2020. You have also been 
asked to pay $2,467.68, or less than 20% coinsurance of the Plan-allowed amount of $14,492.39, for an 
inpatient hospital stay at an out-of-network hospital on February 5 to February 11, 2020. Inpatient hospital 
stays at an out-of-network hospital fall within the "Inpatient hospital care" benefit category. This means that 
you have been asked to pay less than or equal to 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 2 inpatient hospital stays at an out-of-network hospital 
on January 27 to February 2, 2020, and on February 5 to February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 12, 2020 and 
billed under codes 81295, 81292, 81298, and 81321. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare coverage criteria are not met. The Plan says that the enrollee's diagnosis is 
non-Hodgkin's lymphoma, follicular type. The enrollee does not have a Medicare approved diagnosis for this testing.  
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of testing. Based on 
the records provided, Medicare rules for coverage of this service have not been met. Therefore, we decided that 
the Plan does not have to pay for lab services provided to the enrollee on May 12, 2020 and billed under codes 
81295, 81292, 81298, and 81321.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office outpatient visit (99213) provided on September 12, 
2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for office outpatient visit. You say that there was a prior authorization on file. The 
Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 office outpatient visit (99213) provided on 
September 12, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on January 15, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that there should be a $0 
copayment for in-network services. The Plan denied your request. The Plan says the correct coinsurance has 
been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $118.96. The total amount you are being asked to pay is $23.79 ($118.96 x 20% = 
$23.79). Durable medical equipment falls within the durable medical equipment/in-network 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 for durable medical equipment provided by a participating 
provider on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation/kyphoplasty 
surgery. 
 
You asked the Plan to pre-approve these services. You say that you are in pain and cannot function. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that percutaneous vertebral 
augmentation/kyphoplasty are covered when specific criteria are met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted imaging studies do not 
show that you have new or recent fractures. Current literature also indicates that the requested surgery is not 
effective in fracture treatment. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous vertebral augmentation/kyphoplasty surgery.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for the ambulance service (A0429) provided on 
November 30, 2018. 
 
You asked the Plan to waive the copayment. You say that an ambulance was not utilized on this date of service 
as your husband passed away before the ambulance could provide transport. The Plan denied your request. The 
Plan says that the copayment has been applied correctly to the service provided. 
 
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 Plan contract does not say in clear and accurate terms that a 
copayment would apply when an ambulance is dispatched, but does not provide transport due to the death of an 
enrollee. 
 
We looked at the contract between the enrollee and the Plan. We did not see where the contract says an 
ambulance copayment would apply when an ambulance has been dispatched, but does not provide transport 
due to the death of an enrollee. We find that an ambulance copayment can only be applied for an actual 
ambulance trip provided. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the copayment for the ambulance service 
(A0429) provided on November 30, 2018.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic mammography, including CAD when performed; 
bilateral (77066) provided May 30, 2019. 
 
You asked the Plan to pay for the diagnostic mammography. You say that the enrollee had multiple exams on 
this date of service. The attached reports support the level of service. Please reconsider for processing. The 
Plan denied your request. The Plan says this is a duplicate of a previously processed claim, billed by the same 
provider. 
 
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, based on the documentation provided, the plan had already approved payment for CPT code 77066 
on check dated 05/31/2020 to the same provider. Based on this information, we decided that Medicare rules for 
coverage of the diagnostic mammography have not been met. Therefore, we decided that the Plan does not 
have to pay for diagnostic mammography, including CAD when performed; bilateral (77066) provided May 
30, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic digital mammogram provided 
by a participating provider on June 11, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic digital mammogram. You say that this was 
supposed to be preventative and covered 100%. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $30 copayment for outpatient diagnostic tests/x-rays and ultrasounds.  
 
The enrollee has been asked to pay a $30 copayment for a diagnostic digital mammogram. The correct 
copayment has been applied to the diagnostic mammogram that was provided. A diagnostic digital 
mammogram falls within the outpatient diagnostic tests/x-rays and ultrasounds 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 for a diagnostic digital mammogram provided by a participating 
provider on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient hospital services you 
received on January 16, 2019. 
 
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible 
for the copayment. 
 
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 outpatient diagnostic tests.  
 
Review of the file shows that you were provided outpatient services on January 16, 2019. You have been asked 
to pay a $50 copayment for the services. The services fall within the outpatient hospital 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 the outpatient hospital services you received on 
January 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that your facility specializes in lymphedema 
therapy. The Plan denied your request. The Plan says the requested service is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a 
pneumatic compression device to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Baclofen injections (J0475) provided on January 28, 2020. 
 
You asked the Plan to pay for Baclofen injections. You say that this is documented in the records. The Plan 
denied your request. The Plan says the four units billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 4 units of CPT code J0475 are not supported in the medical record. Each unit of J0475 represents 
10 mg of Baclofen, and the records document that 20 mg were administered to the enrollee on this date of 
service. Based on this information, we decided that Medicare rules for coverage of Baclofen injections have not 
been met. Therefore, we decided that the Plan does not have to pay for Baclofen injections (J0475) provided on 
January 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
surgical repair of left hip fracture. Medical problems are stable. There are no identified problems that need 
inpatient medical management. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but 
it does not support a need for an intensive rehabilitation therapy program. We looked at this physician's review, 
the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF 
care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient 
rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe wound therapy pump and supplies you received on February 4, 2020.You asked the Plan to waive the coinsurance forthe wound therapy pump and supplies. You say that all of these items should be provided with no copayment because you were getting home health care.The Plan denied yourrequest. The Plan says you were charged this coinsurance correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay 20% coinsurance for the wound therapy pump and supplies. The wound therapy pump and supplies fall within the durable medical equipment and related supplies benefit category. These items are not part of the home health benefit category because they were provided by a durable medical equipment company, not a home health agency. 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 wound therapy pump and supplies you received on February 4, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you are not ready to be discharged. The Plan 
denied your request. The Plan says that you are not a candidate for continued SNF services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable toilet. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee requires a specialty 
commode to increase independence with toilet transfers. The Plan denied your request. The Plan says products 
that help with hygiene are not covered. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that the enrollee is confined to a bed or room as defined by Medicare rules. Equipment 
used for a patient's comfort or for the convenience of a person caring for the patient is not covered. Therefore, 
we decided that the Plan does not have to pre-approve a portable toilet.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone density measurement of the core or central skeleton 
(77080) provided on January 16, 2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the bone density measurement of the core or central skeleton. You say that you 
were advised the facility was in network. The Plan denied your request. The Plan says prior authorization was 
not obtained by the facility or the provider; therefore, payment has been correctly denied. 
 
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 bone density measurement of the core or 
central skeleton (77080) provided on January 16, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist visit you had on April 8, 
2018. 
 
You asked the Plan to waive the copayment. You say that you did not have to pay a copayment the last time 
you received this service. The Plan denied your request. The Plan says you are responsible for the copayment. 
 
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 each specialist visit.  
 
Review of the file shows that you had a specialist visit on April 8, 2018. You have been asked to pay a $30 
copayment for the visit. The visit falls within the physician 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 the specialist visit you had on April 8, 2018.