Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) provided on 
February 22, 2020. 
 
You asked the Plan to pay for a shoulder elbow wrist hand orthosis. You say that this should be covered. The 
Plan denied your request. The Plan says this was not ordered in connection to a covered telehealth vistit. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder elbow wrist hand 
orthosis (L3960) provided on February 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 3, 2019 to 
September 9, 2019. 
 
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The 
Plan denied your request. The Plan says this provider is not a Medicare eligible contracted provider. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program.  
The services at issue were rendered by a provider that has opted out of the Medicare program. Therefore, we 
decided that the Plan does not have to pay for chiropractic services provided from January 3, 2019 to 
September 9, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EGD provided on January 22, 2020. 
 
You asked the Plan to waive the copayment for an EGD. You say that you were not informed that a biopsy was 
being done until after the procedure was completed. 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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
The medical records show that you received an EGD on January 22, 2020. An EGD is considered a diagnostic 
surgical procedure. Therefore, you are responsible to pay the $200 copayment.  
 
You have been asked to pay a $200 copayment for an EGD. An EGD 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 an EGD provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for allergen immunotherapy services provided 
from January 2, 2020 to April 21, 2020. 
 
You asked the Plan to waive the deductible for allergen immunotherapy services. You say that you disagree 
with the charges because you are paying much more than you did with a previous plan. 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. Your 
contract with the Plan says that there is a $400 deductible for physician/practitioner services, including doctor's 
office visits.  
 
You received allergen immunotherapy services provided from January 2, 2020 to April 21, 2020 for a total of 
17 services. The record shows that you had paid $0 toward the deductible prior to receiving the services. 
Therefore, you are responsible to pay the allowed amount of $7.75 per each service. The total amount you owe 
is: $131.75. 
 
You received immunotherapy services on March 20, 2020. The record shows that you had not met the 
deductible amount at the time. Therefore, you are responsible to pay the total allowed amount of $190.80.  
 
The total amount you owe is: $322.55. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services, including doctor's office visits.  
 
 
 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible for 
physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that 
had not been met at the time allergen immunotherapy services were received on January 2, 2020 to April 21, 
2020. Therefore, we decided that the Plan does not have to waive the deductible for allergen immunotherapy 
services provided from January 2, 2020 to April 21, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the intravenous therapy provided on March 13, 2020. 
 
You asked the Plan to waive the coinsurance for the intravenous therapy. You say that you never had 
intravenous therapy. The Plan denied your request. The Plan says that 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. Your 
contract with the Plan says that enrollees must pay 20% coinsurance for the intravenous therapy. 
 
The Plan says you must pay $54.59 for the intravenous therapy. Based on the Plan contract, however, you 
cannot be asked to pay a separate coinsurance for the intravenous therapy. The record shows you received 
intravenous therapy during your emergency room visit. This means, the intravenous therapy is included in the 
emergency room copayment. Therefore, we decided that the Plan has to waive the coinsurance for the 
intravenous therapy provided on March 13, 2020. 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medroxyprogesterone acetate injection (J1050) rendered 
by the out of network (OON) provider on March 5, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the medroxyprogesterone acetate injection (J1050) rendered by the out of network (OON) 
provider on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist visits provided on July 26, 2019. 
 
You asked the Plan to waive the copayments for specialist visits. You say that you feel that the enrollee should 
only owe one copayment for the services since they were rendered on the same day. The Plan denied your 
request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $45 copayment per visit with a specialist. 
 
The enrollee had two specialist visits on July 26, 2019. Therefore, the enrollee is responsible to pay a $45 
copayment per each visit. The total amount the enrollee owes is $90.   
 
The enrollee has been asked to pay the total copayment amount of $90 for specialist visits. Specialist visits fall 
within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided on July 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a mammogram and an MRI provided from 
October 1, 2019 to January 3, 2020. 
 
You asked the Plan to waive the copayments for a mammogram and an MRI. You say that you already paid 
$25 copayments and you disagree with the additional 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 diagnostic radiology services. 
 
You had a mammogram on October 1, 2019. Therefore, you are responsible to pay the $50 copayment.  
 
You had an MRI on January 3, 2020. Therefore, you are responsible to pay the $50 copayment.  
 
The total amount you owe is: $100.   
 
You have been asked to pay the total copayment amount of $100 for a mammogram and an MRI. A 
mammogram and an MRI fall within the outpatient diagnostic tests and therapeutic services and supplies 
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 a mammogram and an MRI 
provided from October 1, 2019 to January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) 
provided February 19, 2020. 
 
You asked the Plan to pay for the orthoses. You say that a thorough review of this documentation reveals that 
medically necessary supplies were dispensed pursuant to physician orders, which were received by the 
enrollee. The Plan denied your request. The Plan says the billed supply code cannot be verified. 
 
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 orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the documentation provided, while the enrollee is noted to have multiple aches and 
pains, the provided records do not specifically address knee pain/issues.  No detailed history, recent injury or 
surgery, associated symptoms, review of systems or physical examination, including weakness and/or 
deformity, regarding the knees has been documented.  There is no evidence of diagnostic evaluation (i.e. x-
rays) or prescription therapy provision/response (i.e. prescription meds, injections, PT/OT).  Therefore, the 
documentation does not support the medical necessity or reasonableness of the provided service.  
 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis 
provided on January 22, 2020 by an OON provider. 
 
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you 
contacted the Plan and were advised that you have dental insurance coverage up to $1,000 for the year. The 
Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan 
also says that you self-referred to this OON provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. The records show that the Plan confirmed that you were advised that 
OON benefits were not available, and you were given a list of in-network providers. Therefore, we decided that 
the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on January 
22, 2020 by an OON provider.  
 
Your complaint about being misinformed by the Plan 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diagnostic services (IMRT) provided to the enrollee during a 
clinical trial from December 3, 2019 to December 27, 2019. 
 
You asked the Plan to pay for services provided during a clinical trial. You say that these claims should be 
covered by the Plan. The Plan denied your request. The Plan says these services are typically not covered, and 
the enrollee was registered in a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that claims for services provided to an enrollee 
participating in a clinical trial must be submitted to Original Medicare prior to being reviewed by the Plan.  
Services that are not covered normally by the Plan or by Medicare absent participation in the clinical trial also 
are not the responsibility of the Plan. Claims for payment of these services must be submitted to Original 
Medicare for review. Therefore, we decided that the Plan does not have to pay for diagnostic services (IMRT) 
provided to the enrollee during a clinical trial from December 3, 2019 to December 27, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for outpatient therapy provided from November 12, 2019 through 
November 18, 2019. 
 
You asked the Plan to pay for the outpatient therapy. You say that the services were medically necessary. You 
say that the therapy claim met the parameters and requirements for Medicare coverage. The Plan denied your 
request. The Plan says that the services are not authorized. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. There is supporting documentation that this was a Part A covered stay and it was 
billed as outpatient therapy provided to a long-term care resident. Without evidence that payment was made for 
Part A services, the Plan's denial rationale is not substantiated. Therefore, we decided that the Plan has to pay 
for outpatient therapy provided from November 12, 2019 through November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 19, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
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 lab services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no medical justification for the testing performed with nasopharyngeal swab by GTI on 
March 19, 2020. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab services provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a chiropractic office visit received on February 28, 2020. 
 
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The 
Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for a chiropractic office visit received on February 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from April 3, 
2020 to April 6, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were waiting to 
receive a colonoscopy but never received it and now are being charged for additional days. 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 $395 
copayment for days 1-4 for inpatient hospital care.  
 
You had an inpatient hospital stay from April 3, 2020 to April 6, 2020. Therefore, you are responsible to pay a 
$395 (copayment) for days 1-3 (April 3, 2020 to April 5, 2020). $395 (copayment) x 3 (inpatient days) = 
$1,185.  
 
You have been asked to pay the total copayment amount of $1,185 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 April 3, 2020 to April 6, 2020.  
 
We note your complaint that you were waiting for a colonoscopy that never happened. Your complaint is a 
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about 
these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the office visit, the optic nerve imaging, and 
the visual field test provided on March 10, 2020. 
 
You asked the Plan to waive the cost share for the office visit, the optic nerve imaging, and the visual field test. 
You say that this visit was cancelled due to COVID-19 and you were not seen. 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. Your 
contract with the Plan says that there is a $390 deductible that applies towards specialist office visits, 10% 
coinsurance for each in-network specialist's office visit, and 10% coinsurance for other outpatient diagnostic 
tests at an in-network specialist's office.  
 
The specialist office visit you asked the Plan to waive the cost share for falls within the ?Physician/ 
Practitioner services, including doctor?s office visits? benefit category. The optic nerve imaging and the visual 
field test falls within the ?Outpatient diagnostic tests and therapeutic services and supplies? benefit category. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $390 deductible that 
applies towards specialist office visits, 10% coinsurance for each in-network specialist's office visit, and10% 
coinsurance for other outpatient diagnostic tests at an in-network specialist's office. The medical record shows 
you were seen in the office on this date of service. See chart below. 
 
  
Date of Service Service Allowed Amount Deductible/Coinsurance Member Liability 
March 10, 2020 Specialist 
office visit 
$116.83 $390 $108.11 ? This is 
where you met the 
deductible 
amount. 
  $8.42 ? This is the 
remaining allowed amount 
($116.83 - $108.11) 
10% $0.84 
March 10, 2020 Optic nerve 
imaging 
$23.50 10% $2.35 
March 10, 2020 Visual field 
test 
$29.02 10% $2.90 
Total    $114.02 
 
This cost sharing is a contractual obligation that had not been met at the time the office visit, the optic nerve 
imaging, and the visual field test were received on March 10, 2020. Therefore, we decided that the Plan does 
not have to waive the cost share for the office visit, the optic nerve imaging, and the visual field test provided 
on March 10, 2020.