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

We decided that the Plan does not have to pay for hospital outpatient services provided on January 20, 2020. 
 
You asked the Plan to pay for the hospital outpatient 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 
item/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 hospital outpatient services provided on January 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 24, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that a phone call to your nurse advised you to 
call for this service. 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 March 24, 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 on March 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an aspiration and/or injection of major joint 
(20611) performed on May 13, 2020. 
 
You asked the Plan to waive the copayment for an aspiration and/or injection of major joint. You say that you 
were not led to expect this charge. 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 $375 
copayment for each outpatient surgery service.  
 
You have been asked to pay $257.86 for an aspiration and/or injection of major joint. An aspiration and/or 
injection of major joint 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 less 
than the full 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 aspiration and/or injection of major joint (20611) performed on May 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on April 22, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 
authorization is required for laboratory services provided out-of-network. 
 
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 April 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (G0482) provided on May 30, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for drug test. You say that you were unaware you needed to obtain prior 
authorization and provided services in good faith. The Plan denied your request. The Plan says prior 
authorization must be obtained for 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 drug test (G0482) provided on May 30, 2019 
by an out of network (OON) provider.
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 6, 2020 to April 6, 2020. 
 
You asked the Plan to waive the coinsurance for a semi-electric hospital bed. You say that you returned the bed 
and did not have it anymore. 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/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a semi-electric hospital bed. The 
total allowed amount is $103.28. The total amount you are being asked to pay is $20.66 ($103.28 x 20% = 
$20.66). A semi-electric hospital bed falls within the durable medical equipment/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 durable medical equipment provided by a participating 
provider on March 6, 2020 to April 6, 2020.  
 
We note your complaint about returning the bed in March. Your complaint is a grievance that must be 
answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee out of network on 
December 31, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 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 services provided to the enrollee out of network on December 31, 
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the microslide consultation and report services provided on 
November 21, 2019. 
 
You asked the Plan to pay for the pathology consultation. You say that this should be paid as the services were 
medically necessary. The Plan denied your request. The Plan says this claim was billed with an outpatient place 
POS code when records show that the enrollee was inpatient. 
 
The Plan must follow Medicare rules. Medicare rules say that for registered inpatients, claims must report an 
inpatient POS code, regardless of where the face to face exam takes place. 
 
In this case, the Plan states that the enrollee was inpatient when the sample was taken. As such, billing with 
POS code 22, for outpatient, is not appropriate. POS code 21 must be used. Therefore, we decided that the Plan 
does not have to pay for the microslide consultation and report services provided on November 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on March 11, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for EKG. You say that the plan does not offer DOT physicals, you were forced to go 
outside the plan where you were required to receive an EKG. The Plan denied your request. The Plan says prior 
authorization is required for 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 electrocardiogram (EKG) provided on March 
11, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal aortic aneurysm (AAA) screening rendered on 
June 23, 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. The rules say that payment may be made for a one-time ultrasound 
screening for AAA. 
 
We looked at the file and Medicare rules. The file shows that you previously received an AAA screening on 
January 24, 2020 for which the Plan approved and paid. This screening is covered once only by Medicare and 
the Plan. The AAA screening on June 23, 2020 exceeds the benefit limit. Therefore, we decided that the Plan 
does not have to pay for the abdominal aortic aneurysm (AAA) screening rendered on June 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayments for the knee x-ray (73564) and the MRI of the 
lower extremity joints (73721) provided on May 20, 2020 and May 27, 2020. 
 
You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services 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 $275 
copayment for advanced imaging services and a $110 copayment for basic radiological services with an in-
network provider at an outpatient hospital setting.  
 
You have been asked to pay $309.49 ($208.98 + $100.51) for the advanced imaging and basic radiological 
services provided. This is the Plan allowed amount and is less than the applicable copayments for these 
services. 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 copayments for the knee x-ray (73564) and the MRI of the 
lower extremity joints (73721) provided on May 20, 2020 and May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care services provided on September 24, 2019 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the custodial care services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 custodial care services provided on September 
24, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular genetic screening test performed on June 3, 
2020. 
 
You asked the Plan to pay for a molecular genetic screening test. You say that this testing was medically 
necessary as it was ordered by the referring physician. The Plan denied your request. The Plan says the rules 
for coverage have not been met. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for a molecular genetic screening test. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that that the enrollee's diagnosis is urinary tract infection. These services are not 
authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on 
the claim and are done for screening purposes. The review has determined that the billed services provided was 
for screening purposes. The billed services were not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the test at issue in this appeal, a molecular genetic screening test, was requested solely for screening purposes. 
Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not 
have to pay for a molecular genetic screening test performed on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacral nerve stimulator.
You asked the Plan to pre-approve a sacral nerve stimulator. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulators are only covered for certain
indications.
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 a sacral nerve stimulator. Our reviewer
says that the documentation does not support that the requested item is medically reasonable or necessary. Our
physician reviewer found the enrollee has diabetic neuropathy. Diabetic neuropathy is nerve damage from
diabetes that may cause difficulty with emptying the bladder. Sacral nerve stimulation is not indicated and
unlikely to be effective. Sacral nerve stimulation is it not medically necessary and reasonable for this enrollee
because diabetic neuropathy excludes coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a sacral nerve stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a sacral nerve stimulator.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transport and ground mileage provided on  December 10, 2019.

You asked the Plan to pay for the transportation services. You say that the enrollee was not enrolled in hospice at the time the services were rendered. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the non-emergency transport and ground mileage provided on  December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received 
from May 13, 2020, to May 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought that all 
of your hospitalizations would be treated as one admission.  You say that you are on a fixed income and cannot 
afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 
correctly. The plan says that you have only been charged a total of $1,474.28 because you hit your out-of-
pocket maximum with this admission. 
 
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 $325 
copayment per day for days 1-6 per admission for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-6 for the inpatient hospital services. Your 
Evidence of Coverage clearly states that this copayment is owed per 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 waive the copayment for the inpatient hospital services you received from May 13, 2020, to May 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP mask you received on April 20, 
2020, from an out-of-network provider. 
 
You asked the Plan to waive the coinsurance for the CPAP mask. You say that you were told that this provider 
is in-network. The Plan denied your request. The Plan says you were charged this coinsurance correctly. This 
provider is not in-network.  In-network providers do not require you to purchase items up-front and request 
reimbursement later. Phone records from April 17, 2020 show that you were advised prior to receiving this 
item that the provider is out-of-network and you would be responsible for 30% coinsurance. 
 
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 30% 
coinsurance for durable medical equipment and supplies received from out-of-network providers.  
 
You have been asked to pay 30% coinsurance for the CPAP mask. 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 CPAP mask you received on April 20, 2020, from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for miscellaneous DME supply, portable battery charger 
(A9900) purchased February 20, 2020. 
 
You asked the Plan to pay for the portable battery charger. You say that what you are looking for is a logical 
person to look at your claim and appeal and realize the issue and reimburse the 80% if the charging cables cost 
which was $199.50 x 80% reimbursement = $159.60. The Plan denied your request. The Plan says for power 
mobility devices the battery should be included in the price of the wheelchair and is not separately 
reimbursable. The portable battery charger is a convenience item. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature and is for use 
outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for 
use outside the home. Therefore, we decided that the Plan does not have to pay for miscellaneous DME supply, 
portable battery charger (A9900) purchased February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the afterhours office visit provided on April 1, 2020. 
 
You asked the Plan to pay for the afterhours office visit. You say that you had an infection in your gums and 
were given antibiotics to clear up the infection. You say that the afterhours visit should be covered. The Plan 
denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
afterhours office visit provided on April 1, 2020.