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

 
We decided that the Plan does not have to waive the copayment for a stay at a SNF from February 9 to March 9 
and from March 18 to March 29, 2020. 
 
You asked the Plan to waive the copayment for a stay at a SNF. You say that that you are unable to pay the bill. 
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 $150 
copayment for each day for days 21 to 100 of a stay at a SNF within one benefit period.  
 
You have been asked to pay $3,000, or a $150 copayment for each day for 20 days, for a stay at a SNF. A stay 
at a SNF falls within the "Skilled nursing facility (SNF) 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 a stay at a SNF from February 9 to March 9 and from March 18 to March 29, 2020.  
 
Your complaint about being unable to leave the SNF due to the COVID-19 pandemic 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cataract surgery (66984) and the computerized 
ophthalmic diagnostic imaging (92134) rendered by the out of network (OON) provider on February 11, 2020 
and February 19, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 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 cataract surgery (66984) and the computerized ophthalmic diagnostic imaging 
(92134) rendered by the out of network (OON) provider on February 11, 2020 and February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the inpatient hospital care provided June 2, 
2020 to June 6, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 
provided. 
 
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 $300 
copayment per admission for each medically necessary inpatient stay.  
 
You have been asked to pay a $300 copayment for the inpatient hospital admission. 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 adjust the copayment for the inpatient hospital care provided June 2, 2020 to June 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 9, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for dialysis care that you provided on 
November 30, 2019. 
 
You asked the Plan to pay for the physician's services for dialysis care. You say that the patient was in dire 
need for dialysis treatment for his condition and you could not resist treating the patient. The Plan denied your 
request. The Plan says that 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 
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 for dialysis care that you provided on 
November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services for dialysis care that you provided on 
September 30, 2019. 
 
You asked the Plan to pay for the physician's services fir dialysis care. You say that the patient was in dire need 
for dialysis treatment for his condition and you could not resist treating the patient. 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 
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 for dialysis care that you provided on 
September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Unlisted allergy/clinical immunologic service or procedure 
provided on March 19, 2020. 
 
You asked the Plan to pay for Unlisted allergy/clinical immunologic service or procedure (95199). You say that 
the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did 
not support the billed service. 
 
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 95199 is not supported in the medical record. Specifically, the medical records do not 
indicate that Unlisted allergy/clinical immunologic service or procedure was performed. Based on this 
information, we decided that Medicare rules for coverage of Unlisted allergy/clinical immunologic service or 
procedure (95199) have not been met. Therefore, we decided that the Plan does not have to pay for Unlisted 
allergy/clinical immunologic service or procedure provided on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided to the enrollee on January 9, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says the records provided do not support the services 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 and provide medical records to support the 
services billed. In this case, the Plan states the records show blood specimen collection is by venipuncture, however, 
the lab requisition states a urine specimen was collected. This means the billed service cannot be verified due to an 
inconsistent specimen. The Plan states multiple attempts were made to obtain additional information from the provider. 
Based on this information, we decided that Medicare rules for coverage of this testing have not been met. 
Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on January 9, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital provided to the enrollee from 
February 2, 2020 to February 10, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee received medically 
necessary inpatient treatment of broad-spectrum IV antibiotic ceftriaxone. The Plan denied your request. The 
Plan says the claim was billed as an inpatient stay, but only meets the criteria for observation status. 
 
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 documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found based on the medical records provided, the record does not show that at the time of 
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. Care at the observation level appears 
to have been appropriate with the option to transition the enrollee to inpatient status if their condition warranted 
further hospital level care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital provided to the enrollee from February 2, 2020 to 
February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded G0483, 80307, 80157, 
80177,80201, 80162, 80159, and 80173 provided on December 11, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes G0483, 80307, 80157, 80177,80201, 80162, 80159, and 80173 are not supported in the 
medical record. Specifically, the documentation submitted did not include a valid physician order/lab 
requisition form or medical records signed by the ordering physician stating exactly what tests were to be 
performed. In addition, blood specimen collection is by venipuncture, however, the lab requisition states a 
urine specimen was collected. Based on this information, we decided that Medicare rules for coverage of the 
laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the 
laboratory services coded G0483, 80307, 80157, 80177,80201, 80162, 80159, and 80173 provided on 
December 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a revision of a total hip arthroplasty (27134) provided on 
October 28, 2019. 
 
You asked the Plan to pay for the revision. You say that you would like reconsideration because your services 
were deemed medically necessary for the safety of the member. The Plan denied your request. The Plan says 
certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services 
(CMS) guidelines. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for a revision of a total hip arthroplasty 
(27134) provided on October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80159, 
and 80173 provided on December 23, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80157, 80177, 80201, 80159, and 80173 are not supported in the medical record. 
Specifically, the documentation submitted did not support that Carbamazepine; free testing, Levetiracetam 
testing, Topiramate testing, Clozapine testing, or Haloperidol testing were performed. Blood specimen 
collection is by venipuncture; however, the lab requisition states a urine specimen was collected. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 
80201, 80159, and 80173 provided on December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on January 29, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to 
be performed and some of the tests billed do not match the specimen type for testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan 
does not have to pay for laboratory testing provided on January 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EGD with biopsy (43239) provided on November 13, 2019.

You asked the Plan to waive the copayment for the EGD with biopsy. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 per visit for outpatient surgery or procedure at an ambulatory surgical center. 

You have been asked to pay a $195.26 copayment for the outpatient procedure provided at the ambulatory surgical center. This is the Plan allowed amount and is less than the applicable copayment. 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 EGD with biopsy (43239) provided on November 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for wound debridement provided from 
February 14, 2020 to February 28, 2020. 
 
You asked the Plan to waive the copayments for wound debridement. You say that you used to pay $20 per 
each service and cannot afford the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You received wound debridement from February 14, 2020 to February 28, 2020 for a total of 3 services. 
Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a 
$225 copayment per each service. The total amount you owe is: $225 (copayment) x 3 (outpatient surgery 
services) = $675.  
 
You have been asked to pay the total copayment amount of $675 for wound debridement. Wound debridement 
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 copayments for wound debridement 
provided from February 14, 2020 to February 28, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a maxillary partial denture (D5213) and a mandibular partial 
denture (D5214). 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you would like 
to replace the enrollee's missing teeth with upper and lower dentures. The Plan denied your request. The Plan 
says that the provided x-rays are not the most current x-rays of the enrollee's teeth or mouth. 
 
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. The Plan covers the maxillary 
and mandibular partial dentures when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the maxillary and mandibular partial 
dentures. Our reviewer says that the partial dentures are medically necessary. Our physician reviewer found 
due to the lack of functional posterior teeth, the documentation supports the need for the maxillary and 
mandibular partial dentures to restore masticatory function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the maxillary and mandibular partial dentures have been met. Therefore, we 
decided that the Plan has to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture 
(D5214).  
 
 
 
 
 
 
 
 
 
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 waive the copayment for wound care provided  on March 6, 2020 to March 20, 2020. 
 
You asked the Plan to waive the copayment for wound care. You say that this should be covered under your 
wound care benefit not your outpatient benefits. The Plan denied your request. The Plan says the correct 
copayments have 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 $225 
copayment for outpatient surgery/hospital facility.  
 
You have been asked to pay a $225 copayment for each outpatient surgery. The total amount you are being 
asked to pay is $ 675 ($225 x 3 surgeries = $675). Wound care is considered an outpatient surgery; therefore, 
the correct copayments have been applied. Wound care falls within the outpatient surgery/hospital facility 
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 wound care provided on March 6, 2020 to March 20, 2020.