Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the charges for glasses ordered on February 17, 2020. 
 
You asked the Plan to waive the charges for the glasses. You say that you would like reconsideration because 
you have not received the glasses you ordered. The Plan denied your request. The Plan says provider outreach 
has concluded that these glasses were sent to the provider's location on February 24, 2020. 
 
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 covers eyeglasses once per calendar year. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the glasses have not been met. Specifically, the record indicates that your glasses were sent to the 
provider's office. The Plan has confirmed that these glasses are available to you. Therefore, we decided that the 
Plan does not have to waive the charges for glasses ordered on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis (LSO) rendered on April 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that an LSO 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 pay for these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee was evaluated on April 11, 
2019. There was no documented evaluation of the back at that time. The available documentation in the case 
file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the 
enrollee. The documentation does not support that the lumbar-sacral orthosis was ordered for one of the 
following indications: to reduce pain by restricting mobility of the trunk, to facilitate healing following an 
injury to the spine or related soft tissues, to facilitate healing following a surgical procedure on the spine or 
related soft tissue, or to otherwise support weak spinal muscles and/or a deformed spine. 
 
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 pay for the lumbar-sacral orthosis (LSO) rendered on April 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the breast augmentation services provided on November 11, 
2019. 
 
You asked the Plan to pay for the services provided. You say that your implants needed to come out as soon as 
possible. The Plan denied your request. The Plan says reconstruction of the breast after removal of implants 
that were not placed after cancer surgery are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic surgery or expenses incurred in 
connection with such surgery is not covered. 
 
We looked at the file and Medicare rules. The records provided do not indicate that augmentation was provided 
following a medically necessary mastectomy. Cosmetic surgery for the sole purpose of improving one?s 
appearance is not covered. Based on this information, we decided that Medicare rules for coverage of the 
services provided have not been met. Therefore, we decided that the Plan does not have to pay for the breast 
augmentation services provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telehealth visit you had with a 
neurologist on March 20, 2020. 
 
You asked the Plan to waive the copayment for the telehealth visit. You say that you had a telephone call with 
your neurologist to go over test results, but you should not be billed for this service. The Plan denied your 
request. The Plan says you were charged this amount 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 $45 
copayment for per visit for specialist services.  
 
You have been asked to pay a $45 copayment for the telehealth visit. Your Evidence of Coverage states that the 
specialty visit copayment can apply even if you visit with the doctor over the telephone or video chat?you do 
not have to be physically present in the doctor?s office. 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 telehealth visit you had with a neurologist on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 95937) provided on February 3, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 95937 is "Neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method". 
 
We asked our coding 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 services. Our reviewer says that the use 
of CPT code 95937 is not supported by the records provided. Our coding reviewer found that the procedure 
report did not include neuromuscular junction testing. Train of four testing would not be reported under CPT 
95937. 
 
We looked at this coder?s review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT 95937) provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for speech generating device, synthesized speech, requiring 
message formulation by spelling and access by physical contact with the device (CPT Code E2508) provided 
on February 12, 2020. 
 
You asked the Plan to pay for the item. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the item have not been met. Healthcare Common Procedure 
Coding System (HCPCS) code E2508 NU KX (1 Unit) remains not supported. The documentation submitted 
did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery to 
indicate that the specific item was delivered to the patient. Therefore, the billed supply code cannot be verified. 
It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we 
decided that the Plan does not have to pay for speech generating device, synthesized speech, requiring message 
formulation by spelling and access by physical contact with the device (CPT Code E2508) provided on 
February 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on April 29, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in hospice on the date of service in question. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the services provided on April 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on April 7, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on April 7, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on April 
7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 13, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that this testing enabled the enrollee's treating physician 
to determine the optimal treatment pathway. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because this provider is out-of-network with the Plan and there was not an in-
network referral for this testing. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on April 13, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the lab testing provided on March 3, 2020. 
 
You asked the Plan to waive the copay for the lab tests. You say that an annual check-up has no copays. The 
Plan denied your request. The Plan says the appropriate copay was assessed for the services. 
 
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 
copay for laboratory tests.  
 
You have been asked to pay a $20 copay for the lab tests. The testing falls within the outpatient diagnostic tests 
benefit category. Furthermore, your plan contract says that cost-sharing may apply for other services provided 
during the annual physical exam. 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 copay for the lab testing provided on 
March 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram you received on 
January 24, 2020. 
 
You asked the Plan to waive the copayment. You say that there should be no 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 $25 
copayment for non-radiological diagnostic services.  
 
Review of the file shows that you had an electrocardiogram on January 24, 2020. Per your contract with the 
Plan, there is a $25 copayment non-radiological diagnostic services. This cost sharing is a contractual 
obligation that you agreed to pay when you enrolled in plan name. However, the Medicare allowed amount for 
these services was$16.75. Given that the allowed amount was less than the $25 copayment, you have been 
asked to pay $16.75. 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 electrocardiogram you 
received on January 24, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on February 5, 2020 by a 
non-network 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 a non-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 referring provider 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 February 5, 2020 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you do not have information on the enrollee's 
insurance requirements. The Plan denied your request. The Plan says the services were not authorized. 
 
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 and the referring provider in this case are not a network providers with the Plan. The 
Plan has network providers available who can provide the lab services at issue in this appeal. The Plan did not 
pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on February 11, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the specialist office visit provided on 
February 4, 2020. 
 
You asked the Plan to adjust the copayment for the specialist office visit. You say that you saw a nurse 
practitioner so your copayment should be less The Plan denied your request. The Plan says this copayment was 
charged based on the services provided and the Plan contract agreement.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Physician/Practitioner services. 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 adjust the copayment for the specialist office visit 
provided on February 4, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy rendered on November 8, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 45388 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 45388 is colonoscopy, flexible; with ablation of tumor(s), 
polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed). 
 
We find that CPT code 45388 is not supported in the medical record. Specifically, the records support that a 
colonoscopy with cold biopsy forceps was performed and there is a more appropriate code for these services. 
Based on this information, we decided that Medicare rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pay for the colonoscopy rendered on November 8, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copay for the skilled nursing facility (SNF) services 
provided from March 5, 2020 to April 7, 2020. 
 
You asked the Plan to waive the copay for the SNF services. You say that you were misled. The Plan denied 
your request. The Plan says the original processing of the claim is correct. 
 
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 $0 
copay for days 1-20, and a $160 copay each day for days 21-51 for skilled nursing facility care.  
 
The file shows that you received 33 days of SNF care. You were not charged a copay for days 1-20. For the 
remaining 13 days, a $160 copay was applied, totaling $2080. The services fall within the skilled nursing 
facility 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 copay for the skilled nursing facility 
(SNF) services provided from March 5, 2020 to April 7, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for hyperbaric oxygen under pressure, full 
body chamber, per 30 minute interval (G0277) provided March 5, 2020 to March 31, 2020. 
 
You asked the Plan to waive the copayment for hyperbaric oxygen under pressure. You say that before getting 
your treatments, you made sure and was told the plan authorized full coverage for the treatments. You thought 
the maximum copay was 20%. But the plan paid 67.7% and your copay is 37.3%. The Plan denied your 
request. The Plan says the claims processed correctly and the correct cost share applied correctly per the 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 $295 
copayment for Medicare covered surgery or other services provided to you at an outpatient hospital.  
 
You have been asked to pay $3,220 ($295 x 10 days = $295.50 + $270 as there was a remaining amount of 
$270.00 for the $3,950.00 out-of-pocket maximum totaling $3220). The hyperbaric treatments fall within the 
outpatient surgery and other medical 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 hyperbaric oxygen under 
pressure, full body chamber, per 30 minute interval (G0277) provided March 5, 2020 to March 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient services provided on October 25, 2019 through 
November 1, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that you would like reconsideration because the 
inpatient services were medically necessary. The Plan denied your request. The Plan says a review of the 
medical records submitted did not validate the secondary diagnosis of R65.21 for Severe Sepsis with Septic 
Shock for this admission. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 
 
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 inpatient services. Our reviewer says that 
the medical records did not support the secondary diagnosis, R65.21. Our physician reviewer found there was 
no physician query submitted with medical records despite the physician documentation vacillating between 
Sepsis with septic shock and sepsis without shock. The physician progress notes, ICU notes, step down unit 
physician notes, Infectious disease consultation notes, document Severe sepsis without septic shock. 
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pay for inpatient services provided on October 25, 2019 through November 1, 2019.