Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided by a 
participating provider on January 2, 2020. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you do not agree with this 
copayment. The Plan denied your request. The Plan says these services were not provided by your primary care 
physician. The Plan says that 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 $20 
copayment for urgently needed services.  
 
You have been asked to pay a $20 copayment for urgent care services. The correct copayment has been applied 
for these services. Urgent care services fall within the urgently needed services benefit category. This means 
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for urgent care services provided by a participating provider on January 
2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered by the out of network 
(OON) provider on March 13, 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 laboratory services rendered by the out of network (OON) provider on March 13, 
2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the wound debridement (11042) provided 
on March 31, 2020. 
 
You asked the Plan to waive the copayment. 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 $225 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay a $225 copayment for the outpatient surgery provided. The Plan contract states 
that this copayment applies to each Medicare-covered outpatient hospital facility visit. 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 wound debridement (11042) provided on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 6, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
that 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 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 subsequent nursing facility care provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an oxygen concentrator provided on February 20, 
2020. 
 
You asked the Plan to reimburse you for the oxygen concentrator. 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 reimburse you 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 
oxygen concentrator. We found no exception that would require the Plan to reimburse you for this item. 
Therefore, we decided that the Plan does not have to reimburse you for an oxygen concentrator provided on 
February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the massage therapy rendered on March 11, 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 does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for the massage therapy rendered on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the office visits (99203, 99213) provided 
on March 16, 2020 and March 27, 2020. 
 
You asked the Plan to waive 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 $40 
copayment for an in-network specialist office visit.  
 
You have been asked to pay $80 ($40 copayment x 2 visits) for the specialist office visits provided. 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 the office visits (99203, 99213) provided on March 16, 2020 and 
March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 11, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for surgical services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because this provider is 
out-of-network with the Plan and the referring provider was also out-of-network with the Plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 11, 
2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the surgery services and emergency care 
you received on November 25, 2019, and March 13, 2020. 
 
You asked the Plan to waive the copayments. The Plan denied your request. The Plan says you are responsible 
for the cost share. 
 
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 outpatient surgery services. Your contract also says that you must pay a $120 copayment for 
emergency care. 
 
Review of the file shows that you were provided outpatient surgery services and emergency care on November 
25, 2019, and March 13, 2020. You have been asked to pay a $275 copayment for the surgery services and a 
$120 copayment for the emergency care. 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 surgery 
services and emergency care you received on November 25, 2019, and March 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network 
provider on March 12, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 you by an out-of-network provider on March 
12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Macula Risk genetic testing provided on January 27, 
2020. 
 
You asked the Plan to pre-approve genetic tests. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because this testing is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary 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 pre-approve genetic tests. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no medical records for review. The documentation does not support that this testing 
would impact the health of the enrollee. Testing which has no proven benefit for the management of a medical 
condition of an enrollee is not a Medicare benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Macula Risk genetic testing provided on January 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on November 25, 2019. 
 
You asked the Plan to pay for the physician's 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 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 November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a drug test provided on January 14, 2019. 
 
You asked the Plan to pay for the drug test. You say that you were not aware that prior authorization was 
required. The Plan denied your request. The Plan says plan covers emergency or urgently needed care from an 
out-of-network provider. If the enrollee needs care that our plan covers and our network providers cannot give 
it to you, you can get the care from an out-of-network provider. Prior authorization from the plan is required for 
out-of-network providers. 
 
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 
drug test. 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 a drug test provided on January 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical collar provided on March 18, 2020.
You asked the Plan to pay for the cervical collar (L0180). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the physician listed confirmed he did not order this orthosis. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the enrollee in accordance with Medicare policies. You can find this in the Medicare Program Integrity Manual Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.3.2.4 entitled Signature Requirements. The record does not contain a valid physician order for the supplies provided in this case. A review of the documentation shows the medical records do not mention or support medical necessity for the orthosis
and the physician order is invalid. Therefore, we decided that the Plan does not have to pay for the cervical collar provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pontic and retainer crown provided on February 4, 2020. 
 
You asked the Plan to pay for the pontic and retainer crown. You say that you needed to have the bridge 
replaced. You say that the procedure should be covered at least 40%. The Plan denied your request. The Plan 
says the services are not covered benefits. 
 
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 pontic 
and retainer crown provided on February 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster vaccine and administration charge provided on 
March 12, 2020. 
 
You asked the Plan to pay for the Zoster vaccine and administration charge. You say that you were told your 
insurance covered this and you are on a very limited income. The Plan denied your request. The Plan says this 
vaccine and charge is not covered under your Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster vaccine 
and administration charge. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the Zoster vaccine 
and administration charge. Therefore, we decided that the Plan does not have to pay for the Zoster vaccine and 
administration charge provided on March 12, 2020.  
 
Benefits for the Zoster vaccine and administration charge may be available under Medicare Part D. Contact the 
Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from March 28, 2019 to May 10, 
2019. 
 
You asked the Plan to pay for inpatient care. You say that this was medically necessary. The Plan denied your 
request. The Plan says care after March 28 was unauthorized post-stabilization care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that the 
post-stabilization care services March 29, 2019 to May 10, 2019 were not medically necessary and reasonable. 
Our physician reviewer found the records show that the enrollee was hemodynamically stable and appropriate 
for ambulance transport to a Plan facility. The review has determined that the treating physician did not 
document that the patient was not stable for transfer on any dates of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care have not been met. Therefore, we decided that the Plan does not 
have to pay for inpatient care provided from March 28, 2019 to May 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided  
January 26, 2020 to February 6, 2020. 
 
You asked the Plan to waive the copayment. 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 $250 
copayment per day for days 1-7 and a $0 copayment per day for days 8-90 for Medicare-covered inpatient 
hospital care.  
 
You have been asked to pay a $1,750 copayment ($250 x 7 days) for inpatient hospital care provided. 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 care provided January 26, 2020 to 
February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 7, 2020. 
 
You asked the Plan to pay for the physician's 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 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 January 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5050, V5264, S9999) provided January 8, 
2020. 
 
You asked the Plan to pay for the hearing aids. You say that the hearing aids should be covered. The Plan 
denied your request. The Plan says hearing aids are only covered when obtained from the plan-preferred 
supplier. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained from the plan contracted provider.  
 
We looked at the file and the Plan's rules. The record shows the hearing aids were obtained out-of-network and 
not from the plan's contracted provider. Based on this information, we decided that the Plan's rules for coverage 
of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids 
(V5050, V5264, S9999) provided January 8, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on June 26, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the enrollee was 
enrolled in Hospice on the date of service in question. 
 
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 services provided on June 26, 2019.