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

We decided that the Plan does not have to pay for an ear cartilage graft (21235) provided on February 19, 2020.
You asked the Plan to pay for an ear cartilage graft. You say that this graft is documented in the records. The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code (21235) is graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft). We find that CPT code (21235) is not supported in the medical record. Specifically, the records do not document that ear cartilage was used for the graft. Based on this information, we decided that Medicare rules for coverage of an ear cartilage graft have not been met. Therefore, we decided that the Plan does not have to pay for an ear cartilage graft (21235) provided on February 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the optometry services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the optometry services. You say that you have used this optometrist for years and would like to continue to see him. The Plan denied your request. The Plan says there are in-network providers that can provide the same level of service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the optometry services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance supplies and wait time (A0420, A0382, A0422, A0382) provided February 5, 2020.
You asked the Plan to pay for the ambulance supplies and wait time. You say that the claim should be paid. The Plan denied your request. The Plan says the non-emergency transport code has been paid at the allowed amount. The additional codes for supplies and wait times are not covered codes and cannot be paid.
The Plan must follow Medicare rules. Medicare rules say that costs related to ambulance supplies are included in payment for the ambulance transport. We looked at the file and Medicare rules. The plan has paid the applicable non-emergency ambulance transport costs. The codes billed by the provider for supplies and waiting time are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies and wait time have not been met. Therefore, we decided that the Plan does not have to pay for ambulance supplies and wait time (A0420, A0382, A0422, A0382) provided February 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 22, 2020.
You asked the Plan to pay for the ambulance services. You say that these services were medically necessary. The Plan denied your request. The Plan says that these services a not 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 January 22, 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 January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (T4521).
You asked the Plan to pre-approve incontinence supplies. You say that the requested items are medically necessary. The Plan denied your request. The Plan says the requested supplies are not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4521).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on December 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON nursing facility care. You say that this was a medically necessary service provided in good faith. The Plan denied your request. The Plan says this service was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider 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 nursing facility care (99309) provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the TENS device, four or more leads, for multiple nerve stimulation (E0730).
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Medicare does not cover a TENS machine for chronic low back pain unless you are enrolled in an approved study. You are not enrolled in an approved study. Therefore, we decided that the Plan does not have to pre-approve the TENS device, four or more leads, for multiple nerve stimulation (E0730).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on review of the available records, the enrollee does not meet criteria for IRF 
admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine 
and rehabilitation (PMR) Physician or needs acute rehab nursing care. They may benefit from further physical 
therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission 
is not medically necessary based on the enrollee's current functional status and medical stability. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and copayment for an inpatient hospital stay 
from March 8, 2020 to March 10, 2020. 
 
You asked the Plan to waive the deductible and copayment for an inpatient hospital stay. You say that you 
disagree with the charges because you entered the hospital in pain and left in pain and the doctor was unable to 
place a stent. 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. Your 
contract with the Plan says that there is a $300 deductible. Your contract with the Plan also clearly says that 
after the $300 deductible has been met, enrollee's must pay 10% coinsurance for inpatient hospital care. 
 
You had an inpatient hospital stay from March 8, 2020 to March 10, 2020. Therefore, you are responsible to 
pay the $300 deductible. Now that the deductible has been met, you are also responsible to pay 10% 
coinsurance on the difference between the allowed amount and that amount that applied toward the deductible. 
$8,004.54 (allowed amount) - $300 (deductible) = $7,704.54 and 10% of that is $770.45. The total amount you 
owe is: $300 (deductible) + $770.45 (coinsurance) = $1,070.45.   
 
The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit 
category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that 
there is a $300 deductible. The Plan has also followed Medicare rules by clearly disclosing in the contract that 
after the $300 deductible has been met, enrollee's must pay 10% coinsurance for inpatient hospital care. This 
cost sharing is a contractual obligation that had not been met at the time an inpatient hospital stay was received 
on March 8, 2020 to March 10, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible and copayment for an inpatient hospital stay from March 8, 2020 to March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 2, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you were never charged in the 
past and disagree with 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 $20 
copayment for specialist services.  
 
You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls 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 copayment for a specialist visit provided on April 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on December 11, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-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 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 medical services provided to the enrollee by an out-of-network provider 
on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 ules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $35 copayment for physician/practitioner services/in-network/specialist. 
You can find this information on pages 4-50 to 4-57 of the Plan's 2020 Evidence of Coverage (EOC).  
 

We decided that the Plan does not have to waive the copayment for specialist services provided by a 
participating provider on February 26, 2020. 
 
You asked the Plan to waive the copayment for specialist services. You say that you paid less for this last time. 
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 $35 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay $13.72 which is less than your copayment amount of $35 for specialist services. 
Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on 
February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on June 27, 2019. 
 
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 June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 20, 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 
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 January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99211) provided on February 10, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the services are not supported as performed by the 
rendering provider on the claim. 
 
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 99211 is not supported in the record. Specifically, the record does not indicate that the 
service at issue was rendered by the provider who was billed on the claim. Based on this information, we 
decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the 
Plan does not have to pay for the office visit (99211) provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 17, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 and the referring provider are not network providers 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 January 
17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on December 12, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 24, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on October 24, 2019.
Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to reduce the coinsurance for durable medical equipment. We decided that the 
Plan does not have to waive the coinsurance for durable medical equipment.  
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with this coinsurance. The Plan says that the correct coinsurance has been applied. 
 
We decided that the Plan has to reduce the coinsurance for durable medical equipment.  
 
You cannot be asked to pay more than a 20% coinsurance of the allowed amount for these services. The total 
allowed amount is $396.90. The total amount you are being asked to pay is $79.38 ($396.90 x 20% = $79.38). 
 
We also decided that the Plan does not have to waive the coinsurance for durable medical equipment. 
 
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. Therefore, we decided that the Plan does not have to waive the 
coinsurance for durable medical equipment.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 26, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when 
the specimen was obtained. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The 
claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of 
a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the 
services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services 
provided to the enrollee on February 26, 2020.