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

We decided that the Plan does not have to waive the coinsurance for the B-12 injection provided on March 12, 
2020. 
 
You asked the Plan to waive the coinsurance for the B-12 injection. You say that you should not have a 
coinsurance for your B12 injection. The Plan denied your request. The Plan says the claim has been 
reprocessed and 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 20% 
coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare- Part B covered drugs 
(including certain drugs that are used with nebulizers, insulin pumps, and IV infusions.  
 
You have been asked to pay $0.44 which is 20% of the allowed amount for the B-12 injection. The allowed 
amount is $2.21. ($2.21 x 20% = $0.44). The B-12 injection falls within the ?Medicare Part B prescription 
drugs? 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 the B-12 injection provided on 
March 12, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for supplies and materials (99070) provided on March 1, 
2019. 
 
You asked the Plan to hold you harmless for supplies and materials. You say that this should be reimbursed. 
The Plan denied your request. The Plan says that this was billed incorrectly. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were received supplies and materials from a contract provider. The file does not show that the Plan 
provided notice that supplies and materials would not be covered. Under Medicare rules, this means supplies 
and materials is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless 
for supplies and materials (99070) provided on March 1, 2019.  
 
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 waive the copayment for an x-ray provided by a participating 
provider on May 4, 2020. 
 
You asked the Plan to waive the copayment for an x-ray. You say that you have never had to pay for an x-ray 
before. 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). Your contract with the Plan clearly says that you must pay a $45 
copayment for outpatient diagnostic tests/basic imaging service.  
 
You have been asked to pay $31.63 which is less than your copayment amount of $45 for an x-ray. An x-ray 
falls within the outpatient diagnostic tests/basic imaging service 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 x-ray provided by a participating provider on May 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 16, 2020 by an out of network (OON) 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 an out-of-network 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 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 laboratory services provided on March 16, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the platelet rich plasma injection services identified with code 0232T received on February 27, 2020.
You asked the Plan to pay for the platelet rich plasma injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that services coded 0232T are considered not medically necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the platelet rich plasma injection services have not been met. Therefore, we decided that the Plan does not have to pay for the platelet rich plasma injection services identified with code 0232T received on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies. 
 
You asked the Plan to pre-approve a CGM and supplies. You say that this allows you to check your blood 
sugar more often. The Plan denied your request. The Plan says that documentation fails to indicate that the 
member is being treated with insulin 3 or more times a day. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. 
 
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or 
more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and 
supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) and supplies.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 
24, 2019 to November 27, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges because you feel that all the tests were unnecessary. 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 $310 
copayment per day for days 1-6 for inpatient hospital care.  
 
You had an inpatient hospital stay from November 24, 2019 to November 27, 2019. Therefore, you are 
responsible to pay a $310 copayment for days 1-3 (November 24, 2019 to November 26, 2019). $310 
(copayment) x 3 (inpatient days) = $930.  
 
You have been asked to pay the total copayment amount of $930 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay from November 24, 2019 to November 27, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on 
September 20, 2019. 
 
You asked the Plan to pay for the presumptive and definitive testing. You say that this was medically necessary 
testing. The Plan denied your request. The Plan says the order form does not clearly state what testing is being 
requested. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the 
treating provider. 
 
In this case, the order form indicates the ordering of a panel but the drugs included in this panel are not 
indicated. There is no indication that the panel referenced corresponds to the provider's custom panel. 
Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing 
provided on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a PWC is 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 you do not meet the criteria for coverage. Our physician reviewer found based on the submitted records, you do not meet the criteria for coverage of the requested PWC. The request for power tilt is not supported by the clinical information. There is no documentation of your current functional level assessed by a therapy professional. There is no documentation of pressure sores. Due to the lack of a full evaluation by any therapists, the PWC is not reasonable or medically necessary at this time. 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 a Group 2 power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 22, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on May 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on February 19, 2020 to
February 26, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The
Plan says that the referring facility is also out-of-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 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 skilled nursing services provided on February 19,
2020 to February 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested follow up visit.
You asked the Plan to pre-approve the follow up visit. You say that your current health condition is worsening due to Parkinson's Disease and you would like a follow up visit. The Plan denied your request. The Plan says in-network tertiary care providers can evaluate the 2nd opinion as well as refer for deep brain stimulation when medically necessary. The member is authorized to see in-network equally qualified providers, as is required by the contract. Out-of-network providers are allowed only when the service is medically necessary but unavailable within the network or when an emergency.
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 services. Therefore, we decided that the Plan does not have to pre-approve the requested follow up visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hip belt and gel elbow pads for a power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that the enrollee is a quadriplegic with a seizure disorder and needs the items for quality of life. The Plan denied your request. The Plan says the items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules say that a hip belt is coded as E0978. The requested gel elbow pads do not serve a purpose that is primarily medical in nature and cannot be covered by Medicare. The requested hip belt may be covered if billed correctly. The file shows that the hip belt was requested with code K0108; however, the correct code to request this item is E0978. The Plan states that the hip belt can be covered when coded correctly. Therefore, we decided that the Plan does not have to pre-approve a hip belt and gel elbow pads for a power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 23, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a consultation and you 
should not be responsible for 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 specialist visits.  
 
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor?s office visits 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 specialist visit provided on April 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.
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. There is no documentation provided necessitating admission to a LTACH. The member can remain in the current acute care location until considered medically stable by the treating team. When considered medically stable she may be an appropriate candidate for care at a less intense level such as a skilled nursing facility. Our physician reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MyRisk hereditary cancer update panel provided to the enrollee on January 22, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says there is insufficient evidence to support the validity and utility of this test.
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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review.
Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). In general, tests related to an enrollee's specific symptom/diagnosis are medically necessary and reasonable, but panel testing, with tests unrelated to an enrollee's specific symptom/diagnoses, is not medically necessary and reasonable. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the MyRisk hereditary cancer update panel provided to the enrollee on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the specialist services provided on March 
31, 2020 and May 19, 2020. 
 
You asked the Plan to waive the cost shares for the services provided. You say that you don't want to pay the 
cost sharing for allergy shots. The Plan denied your request. The Plan says you are responsible for specialist 
office visits. 
 
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 
copay per visit for specialist services for physician services.  
 
You have been asked to pay $13.58 per visit for the services provided. Because the amount is less than the $30 
copay, you were charged for the lesser amount. The services fall 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 cost shares for the specialist services provided on March 31, 2020 and May 
19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay the full cost for a walker (E1399, S9999) provided on January 7, 
2020. 
 
You asked the Plan to pay the full cost for a walker. You say that you should be fully reimbursed. The Plan 
denied your request. The Plan says this processed correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% 
coinsurance for durable medical equipment such as walkers.  
 
You have been asked to pay a 10% coinsurance for a walker. 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 the full cost for a 
walker (E1399, S9999) provided on January 7, 2020.  
 
Your complaint about the difference between the allowed amount and the amount you paid is not a valid appeal 
for medical coverage. This part of your complaint 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic testing provided on November 14, 2019.

You asked the Plan to waive the cost share for the services provided. You say that if you would have known it would cost so much, you would not have had the service done. The Plan denied your request. The Plan says the claim processed correctly based on your plan 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). Your contract with the Plan clearly says that you must pay a $10 copay after the deductible is met for each basic imaging service. 

The file shows that you received a transthoracic echocardiography. You were charged $465.48 for the services provided. The services fall within the outpatient diagnostic tests benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible. This cost sharing is a contractual obligation that had not been met at the time the testing was received 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 cost share for the diagnostic testing provided on November 14, 2019.