Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory analyses provided on February 12, 2020. 
 
You asked the Plan to pay for the laboratory analyses. The Plan denied your request. The Plan says the enrollee 
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 laboratory analyses provided on February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Hemoglobin A1C level (83036) 
performed on January 14, 2020. 
 
You asked the Plan to waive the copayment for a Hemoglobin A1C level. You say that you were informed by 
your insurance representative that the cost of this service was part of your office-visit copayment. The Plan 
denied your request. The Plan says the correct copayment 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 a $10 
copayment for each covered lab service.  
 
You have been asked to pay $9.71 for a Hemoglobin A1C level. A Hemoglobin A1C level falls within the 
outpatient diagnostic tests benefit category. This means that you have been asked to pay less than the full and 
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 Hemoglobin A1C level (83036) performed on January 14, 2020.  
 
Your complaint about being provided by a Plan representative with incorrect or misleading information 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on March 19, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 11, 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 the testing is not covered. 
 
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is 
unadulterated is an internal control process that is not separately reportable. 
 
We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for 
drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on 
December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on February 12, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you were told that the hospital was 
in-network. 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 Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $2,857.82. The total amount you are being asked to pay is $571.56 ($2,857.82 x 20% = $571.56). An 
injection falls within the Medicare Part B prescription drugs 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 an injection provided by a participating provider on February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Brimonidine eye drops provided on October 11, 2019 and 
October 12, 2019. 
 
You asked the Plan to pay for Brimonidine eye drops. You say that you had your own eye drops so you should 
not be responsible for the eye drops the hospital provided. The Plan denied your request. The Plan says this 
self-administered drug is not covered by your Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. The self-administered drug was provided while you were in outpatient services. Therefore, 
we decided that the Plan does not have to pay for Brimonidine eye drops provided on October 11, 2019 and 
October 12, 2019.  
 
Benefits for Brimonidine eye drops may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 27, 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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that testing to confirm that a urine specimen is unadulterated is an internal control process that is not separately reportable. We looked at the file and Medicare rules. The file shows that the tests at issue were urine specimens utilized for drug testing. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for post-stabilization inpatient care provided March 14, 2020 to 
March 16, 2020. 
 
You asked the Plan to pay for the post-stabilization inpatient care. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the services were not authorized. The enrollee was 
stable for transfer to a network facility. 
 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the post-stabilization inpatient care. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found based on the 
medical records provided the patient was stable for transfer to a plan facility after initial treatment in the 
emergency room. 
 
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 post-stabilization inpatient care have not been met. Therefore, we decided 
that the Plan does not have to pay for post-stabilization inpatient care provided March 14, 2020 to March 16, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 27, 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 procedure code 29823 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive. We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report does not contain documentation of a surgical shoulder arthroscopy. 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 surgical services rendered on January 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care rendered from December 20, 
2019 to December 21, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the services were not medically necessary. Our physician reviewer found the enrollee presented to the 
emergency department (ED) on December 20, 2019 with shortnessof breath, dizziness, and near-syncope. The 
evaluation revealed stable vital signs and the physical exam was unremarkable. The electrocardiogram (EKG) 
was without any acute ischemic changes and there was no evidence of an active gastrointestinal (GI) bleed. The 
records do not show that, at the time of the inpatient admission, the admitting physician reasonably expected 
that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care rendered from December 20, 2019 to December 
21, 2019.
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 March 18, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you think you are 
being over charged. 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.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $1,220.22. The total amount you are being asked to pay is $244.04 ($1,220.22 x 20% = 
$244.04). Durable medical equipment falls within the durable medical equipment 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 
March 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating 
provider on March 11, 2020. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you want to know why the Plan did not 
pay the full amount. 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 $100 
copayment for outpatient diagnostic tests/in-network/advanced imaging services.  
 
You have been asked to pay a $100 copayment for a CT scan. A CT scan falls within the outpatient diagnostic 
tests/in-network/advanced imaging 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 a CT scan provided by a participating provider on March 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care (99222) provided February 12, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for this service was included in the global 
surgical payment. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99222 is not supported in the medical record. Specifically, the record shows the 
inpatient stay was for a surgical procedure. Payment for the evaluation/management services is included in the 
global surgical payment. Based on this information, we decided that Medicare rules for coverage of inpatient 
hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital 
care (99222) provided February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network acupuncture provided from February 5, 2020 
to March 4, 2020. 
 
You asked the Plan to pay for out of network acupuncture. You say that these services should be covered by the 
Plan. The Plan denied your request. The Plan says out of network acupuncture services 
 
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 Plan contract also specifically states acupuncture must be 
provided in network.  
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the acupuncture for approved medical conditions. The Plan did not pre-approve these services 
out of network and they are not generally covered out of network. 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 out of 
network acupuncture provided from February 5, 2020 to March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 26, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for physician visit. You say that you are entitled to this benefit. The Plan denied 
your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-
network with the Plan and 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 medical services provided on November 26, 
2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health aide services provided from December 9, 2019 
to December 12, 2019. 
 
You asked the Plan to pay for the home health aide services. The Plan denied your request. The Plan says the 
services were received by a provider who is not participating with the plan or with Medicare and, therefore, are 
not covered by the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 home health aide services provided from December 9, 2019 to 
December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 16, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for chiropractic services. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network, authorization was not obtained, and these services are not covered. 
 
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 16, 2020 
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for various services received from March 10, 
2020 to April 2, 2020. 
 
You asked the Plan to waive the cost-sharing for the services. You say that you are disputing this cost share. 
The Plan denied your request. The Plan says the claims were 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 $40 
copayment for physical/speech therapy.  
 
You have been asked to pay the relevant cost-sharing for the services. The services fall within the outpatient 
therapy/prosthetic devices/physician services for outpatient surgery 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-sharing for various services received from March 10, 2020 to April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 7, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services from non-participating providers are not covered under open access unless pre-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 in this case is not a network provider with the Plan. 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 physician's services provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 10, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on February 10, 2020.