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

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a non-
participating provider on November 15, 2019. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that this should be processed as 
in-network services. 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 40% 
coinsurance for outpatient surgery/out-of-network.  
 
You have been asked to pay less than a 40% coinsurance of the allowed amount for an outpatient surgery. The 
total allowed amount is $8,728. The total 40% coinsurance is $3,491.20 ($8.728 x 40% = $3,491.20). The total 
amount you are being asked to pay is $2,338.24. An outpatient surgery falls within the outpatient surgery/out-
of-network benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an outpatient surgery 
provided by a non-participating provider on November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided to the enrollee on 
May 26, 2020. 
 
You asked the Plan to pay for the neuromuscular stimulator. You say that this claim should be paid. The Plan 
denied your request. The Plan says that documentation indicates services are not necessary for treatment of the 
enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the neuromuscular 
stimulator provided to the enrollee on May 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on April 30, 2020. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because the 
documentation submitted does not support the Place of Service (POS) code billed on this claim. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken 
in an office setting, therefore the Place of Service (POS) code 81 ? indicating an independent laboratory setting 
? is not appropriate for 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 April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 23, 2020. 
 
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 documentation submitted did not support the services billed. The type of specimen 
collected is not documented for 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. In this case, this claim cannot be paid due to an 
issue with the type of specimen reported.  Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for lab 
services provided to the enrollee on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient visit (99205) provided July 16, 2020. 
 
You asked the Plan to pay for the office visit. You say that the visit should be paid. The Plan denied your 
request. The Plan says there was a prior new patient visit with a physician from the same group and specialty 
within the past 3 years. 
 
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 99205 is not supported in the medical record. Specifically, the record shows previous 
new patient visits with physicians in the same group with the same specialty code (34) noted on the claim. The 
visit at issue does not meet the criteria of a new patient visit. 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 a new patient visit (99205) provided July 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is still acute. The Plan 
denied your request. The Plan says the documentation does not support that the enrollee will benefit from and 
improve with LTACH management. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer 
found that there are no required medical services identified that are available at the LTACH, that are not 
available at the current health care setting being offered by the Health Plan. Our physician reviewer also found 
that consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for 
the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen equipment purchased on May 19, 2020. 
 
You asked the Plan to pay for oxygen equipment. You say that you were told that this item is covered by 
Medicare. The Plan denied your request. The Plan says the denial of payment for this item is correct, because 
purchased oxygen equipment is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is not covered.  
 
We looked at the file and Medicare rules. You purchased this oxygen equipment. Based on this information, we 
decided that Medicare rules for coverage of oxygen equipment have not been met. Therefore, we decided that 
the Plan does not have to pay for oxygen equipment purchased on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing provided on October 22, 2019. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the billed 
service cannot be verified. 
 
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 G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. In this case, there were 
insufficient medical records to show that the testing was individualized based on clinical history and risk 
assessment. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided 
on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on February 6, 
2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you were supposed to be switched 
to a plan that accepts this provider. You say that you are without therapy that you need and received bills that 
you can't afford. The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse 
practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. 
 
You have been asked to pay a $75 copayment for the office visit. The office visit falls within the 
"Physician/Practitioner Services, Including Doctor?s Office Visits" benefit category. The records show that the 
provider is an out-of-network specialist. 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 office 
visit provided on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on July 16, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this is a 
bundled code, and not payable. 
 
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, we have confirmed that code 99100 is a bundled code. This code cannot be paid as a separate line 
item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the 
Plan does not have to pay for the anesthesia services provided on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transportation services provided on March 16, 
2020. 
 
You asked the Plan to pay for the transportation services. You say that you required emergency medical 
transport for rehab services. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at the file, and Medicare rules. In this case, there were insufficient medical records to show that 
your condition was such that other methods of transportation would be contraindicated. There is no 
documentation that shows you needed the expertise, services, lifesaving and life-sustaining equipment that only 
a fully-equipped ambulance could provide. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance 
transportation services provided on March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the contact lens fitting (92071), eye photography (92285) 
and eye exam (92002) provided on October 3, 2019 to October 14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for contact lens fitting, eye photography and eye exam. You say that you were 
unaware you needed prior authorization. The Plan denied your request. The Plan says prior authorization must 
be obtained for non-emergent services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the contact lens fitting (92071), eye photography 
(92285) and eye exam (92002) provided on October 3, 2019 to October 14, 2019 by an out of network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on March 5, 2020. 
 
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the out-of-
network 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 out-of-network primary care provider visits.  
 
You have been asked to pay a $20 copayment for an office visit. An office 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 an office visit provided on March 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from June 12, 
2020, through June 15, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that this is too much, and you 
cannot pay this bill.  The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment per day, days 1 to 5 at an in-network inpatient hospital. 
 
You have been asked to pay an $850 copayment for the inpatient stay. ($275/day x 3 days = $850). The 
inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for the inpatient stay provided from June 12, 2020, through June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the glycosylated hemoglobin testing provided on April 27, 
2020. 
 
You asked the Plan to pay for the glycosylated hemoglobin testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The glycosylated hemoglobin testing at issue in this appeal 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 the glycosylated hemoglobin testing provided on April 27, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 24, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for ultrasounds. 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 this provider is out-of-
network with the Plan and authorization was not obtained. 
 
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 July 24, 2020 by 
an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on 
October 15, 2019. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not aware that 
your benefits changed for Medicare Part B drugs. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on October 15, 2019. The allowed amount is $9,626.05 and 20% of that 
is $1,925.21.  
 
You have been asked to pay the total coinsurance amount of $1,925.21 for a Medicare Part B drug. A Medicare 
Part B drug falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on July 1, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the service was medically necessary. The Plan denied 
your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-
of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on July 1, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stent placement (37215) performed June 1, 2020. 
 
You asked the Plan to pay for the stent placement. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the facility is not eligible to receive payment for the service at issue. 
 
The Plan must follow Medicare rules. Medicare rules say that Carotid Artery Stenting (CAS) with embolic 
protection is reasonable and necessary only if performed in facilities that have been determined to be 
competent in performing the evaluation, procedure and follow-up necessary to ensure optimal patient 
outcomes.  
 
We looked at the file and Medicare rules. The facility that performed this stenting is not listed on the CMS list 
of facilities eligible to be paid for performing this service. Based on this information, we decided that Medicare 
rules for coverage of the stent placement have not been met. Therefore, we decided that the Plan does not have 
to pay for a stent placement (37215) performed June 1, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
August 20, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER to get an IV 
treatment.  You say that you sat there for hours and left without receiving care.  Because of this, you feel as 
though you shouldn't have to pay a copayment. The Plan denied your request. The Plan says you were charged 
this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency room services.  
 
Records show that you went to the ER on August 20, 2020.  According to the medical records, you were seen 
by hospital staff and you were triaged by the on-duty Nurse Practitioner. You have been asked to pay a $90 
copayment for the ER visit. This copayment applies regardless of the extent of services you receive in the ER. 
his 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 emergency room (ER) visit you had on August 20, 2020.