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

 
We decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the Brain 
(70554) provided. 
 
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied 
your request. The Plan says the service was not pre-authorized or emergent. There were network providers 
available. 
 
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 services 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 these services. Therefore, we decided that the 
Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the Brain (70554) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for medical services you received on March 19, 2019. 
 
You asked the Plan to pay more for the medical services. You say that these bills should be covered in full. The 
Plan denied your request. The Plan says this out-of-network provider accepts Medicare, so they cannot bill you 
more than the Medicare-allowed rate that has already been paid. 
 
The Plan must follow Medicare rules. Medicare rules say that providers that accept Medicare must accept the 
Medicare-allowed rates as payment in full. They are not allowed to balance bill either you or the Plan for any 
amounts above the Medicare allowable rate. 
 
In this case, this provider has already been paid the Medicare allowable rate, so they are not entitled to any 
additional payment from either you or the Plan. Since this provider is an out-of-network provider with the Plan, 
the Plan cannot force the provider to stop billing you inappropriately.

Therefore, we decided that the Plan does not have to pay more for medical services you received on March 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient stay provided by a 
participating provider on March 16, 2020, to April 1, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this 
copayment. 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 $265 
copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care.  
 
You have been asked to pay a $265 copayment per day for days 1-3 for an inpatient hospital stay. The total 
amount you are being asked to pay is $795 ($265 x 3 days = $795). 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 
stay provided by a participating provider on March 16, 2020, to April 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided by a participating 
provider. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you have always paid just 
$25. 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 $450 
copayment for outpatient surgery.  
 
You have been asked to pay a $450 copayment for an outpatient surgery. The injection that was provided is 
considered an injection; therefore, the correct copayment has been applied. An outpatient surgery falls within 
the 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 copayment for an injection 
provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Synvisc injection provided on March 
11, 2020. 
 
You asked the Plan to waive the coinsurance for the Synvisc injection. You say that this was for an injection 
ordered by your in-network provider. You say that you shouldn't be charged out-of-network fees. The Plan 
denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for all other drugs covered under Medicare Part B. 
 
You have been asked to pay $106, which is 20% of the allowed amount for the Synvisc injection. The allowed 
amount is $530 (20% x $530 = $106). The Synvisc injection falls within the "Medicare Part B prescription 
drugs" benefit category. The records show that you were charged the in-network rate for the injection.  
 
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 Synvisc injection provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99205) provided on April 30, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services 
rendered by an out-of-network provider. 
 
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 outpatient office visit (99205) provided on 
April 30, 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 a tumor resection (27365) performed February 18, 2020. 
 
You asked the Plan to pay for the tumor resection. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the CPT code billed. 
 
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 27365 is Radical resection of tumor, femur or knee. 
 
We find that CPT code 27365 is not supported in the medical record. Specifically, the operative report does not 
detail a radical tumor resection. Based on this information, we decided that Medicare rules for coverage of the 
tumor resection have not been met. Therefore, we decided that the Plan does not have to pay for a tumor 
resection (27365) performed February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you are not able to walk and your health is 
declining. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from March 7, 
2019, to March 8, 2019. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the room was necessary 
due to your condition but you disagree with how the claim was processed. 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 $265 
copayment for days 1-8 for inpatient hospital care.  
 
You had an inpatient hospital stay from March 7, 2019, to March 8, 2019. Therefore, you are responsible to 
pay the $265 copayment.  
 
You have been asked to pay a $265 copayment 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 March 7, 2019, to March 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need this so you may walk without pain. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the virtual check-in provided on March 23, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the virtual check-in. You say that you are requesting reimbursement. The Plan 
denied your request. The Plan says the service was rendered by a non-participating provider. 
 
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 
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 virtual check-in provided on March 23, 2020 
by an OON provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted to 
the hospital within 24 hours and that your emergency room copayment should therefore be waived. 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 $120 
copayment for each Medicare-covered emergency room visit.  
 
In this case, documentation in the case record shows that you are held by the hospital for observation. 
Outpatient hospital observation is distinct from an inpatient admission to the hospital. You have been asked to 
pay a $120 copayment for an emergency room visit. An emergency room visit falls within the "Emergency 
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 emergency room visit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for 3 specialist office services (99203, 20610) 
on December 3, December 10, and December 17, 2019, and for 2 Orthovisc injections (J7324) on December 10 
and December 17, 2019. 
 
You asked the Plan to waive the cost-sharing for 3 specialist office services and 2 Orthovisc injections. You 
say that the injections did not work for you and you don't feel the provider should be paid this large amount of 
money for no results. The Plan denied your request. The Plan says the correct cost-sharing was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered Part B drug and a $45 copayment for services obtained from a 
specialist.  
 
You have been asked to pay $114.72, or 20% coinsurance of the Plan-allowed amount of $573.60, for each of 2 
Orthovisc injections. You have also been asked to pay a $45 copayment for each of 3 specialist office services. 
Orthovisc injections fall within the "Medicare Part B prescription drugs" benefit category. Specialist office 
services fall 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 cost-sharing for 3 specialist office services (99203, 20610) on December 3, 
December 10, and December 17, 2019, and for 2 Orthovisc injections (J7324) on December 10 and December 
17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the durable medical equipment rendered 
from January 27, 2020 to January 29, 2020. 
 
You asked the Plan to waive the coinsurance for these services. You say that you were told by the hospital staff 
that the procedure would be covered in full. The Plan denied your request. The Plan says the coinsurance was 
applied 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 20% 
coinsurance for each Medicare-covered durable medical equipment item.  
 
Review of the file shows that you received an implantable joint device from January 27, 2020 to January 29, 
2020. You have been asked to pay a 20% coinsurance for these services. These services fall within the 
Medicare-covered durable medical equipment item benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. The Plan is not denying coverage of these 
services; the amount you are being asked to pay is your contractual cost share amount. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. T Therefore, we decided that the Plan 
does not have to waive the coinsurance for the durable medical equipment rendered from January 27, 2020 to 
January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee brace you received on December 
23, 2019. 
 
You asked the Plan to waive the coinsurance for the knee brace. You say that you didn't receive the knee brace, 
so you shouldn't have to pay this coinsurance. The Plan denied your request. The Plan says you were charged 
this coinsurance correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for durable medical equipment.  
 
The equipment supplier provided records showing that you signed a receipt for the knee brace indicating that 
you had received it. You signed for the delivery on December 23, 2019 (you both printed your name and signed 
it indicating you received this item.) You have been asked to pay 20% coinsurance for the knee brace. The knee 
brace 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 the knee brace you received on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on June 1, 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 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 the neuromuscular 
stimulator rendered on June 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on February 27, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not feel like you 
owe this much. 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 10% 
coinsurance for outpatient surgery/in-network.  
 
You have been asked to pay a 10% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $8,792.10. The total amount you are being asked to pay is $879.21 ($8,792.10 x 10 % = 
$879.21). An outpatient surgery falls within the outpatient surgery/in-network benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the coinsurance for an outpatient surgery provided by a participating provider on 
February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from March 27, 2020, to March 28, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you went to the ER 
and paid your copayment.  You say that you should only have to pay the ER copayment. The Plan denied your 
request. The Plan says you were charged this copayment correctly because you were admitted to the hospital. 
 
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 $150 
copayment per day for days 1-7 for inpatient hospital services.  
 
You have been asked to pay a $150 copayment for the inpatient hospital services. You were admitted to the 
hospital as an inpatient for one day. 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 inpatient hospital 
services you received from March 27, 2020, to March 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided on June 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services received were neither emergent 
nor urgent and prior authorization was not obtained to seek out-of-network 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 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 physician services provided on June 23, 2020 
by an out of network (OON) provider.