Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 23, 
2019 to December 24, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says the enrollee could have been treated in observation. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the records show that the enrollee presented to the emergency room on December 23, 
2019 with shortness of breath that began 4 days prior. He also reported he felt chest tightness with pain in the 
upper back. Aspirin was given and his pain resolved. A stress test was negative. His condition was stable on 
admission and he was discharged with outpatient follow-up on December 24, 2019. The review has determined 
that the record did not show that at the time of inpatient admission the admitting physician reasonably expected 
that the patient's necessary hospital care (including earlier ED and/or observation care) would span two 
midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from December 23, 2019 to December 
24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical and occupational therapy services 
provided from October 7, 2019 to October 8, 2019. 
 
You asked the Plan to waive the copayment for physical and occupational therapy services. You say that you 
do not think you received therapy on these dates. The Plan denied your request. The Plan says these services 
processed 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 $20 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $20 copayment for each physical and occupational therapy service. 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 physical and occupational therapy services provided from October 7, 
2019 to October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on March 11, 
2020. 
 
You asked the Plan to pay for an oxygen concentrator. You say that oxygen equipment has been paid for in the 
past. The Plan denied your request. The Plan says only rented oxygen equipment is covered. 
 
The Plan must follow Medicare rules. purchased oxygen equipment is statutorily non-covered.  
 
We looked at the file and Medicare rules. The record shows this item was purchased rather than rented. Based 
on this information, we decided that Medicare rules for coverage of an oxygen concentrator have not been met. 
Therefore, we decided that the Plan does not have to pay for an oxygen concentrator (E1390) purchased on 
March 11, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on March 1, 
2020. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or facility. 
 
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 to the enrollee on 
March 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5050) purchased from an out-of-network 
(OON) provider on September 12, 2019. 
 
You asked the Plan to pay for hearing aids. You say that hearing aids from in-network providers cannot 
connect to you phone. The Plan denied your request. The Plan says hearing aids are only covered from in-
network providers. 
 
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 provided by a participating provider. 
 
We looked at the file and the Plan's rules. The hearing aids at issue were not purchased from a participating 
provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been 
met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5050) purchased from an out-
of-network (OON) provider on September 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance service (A0428) and 
ambulance mileage (A0425) provided on March 12, 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 after you pay your 
$250 deductible, you pay a $275 copayment for each out of network Medicare-covered one-way trip via ground 
ambulance.  
 
You have been asked to pay a $243.91 copayment for the out of network Medicare-covered one-way ground 
ambulance trip provided. This amount is the allowable charge for this service, which is less than the applicable 
copayment. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for the ambulance service (A0428) and 
ambulance mileage (A0425) provided on March 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient substance abuse rehabilitation provided from 
January 8, 2020 to February 19, 2020. 
 
You asked the Plan to pay for the outpatient substance abuse rehabilitation. The Plan denied your request. The 
Plan says that the Plan contract states that Plan enrollees must use in network providers for getting medical care 
except in emergent or urgent care services. In addition, the enrollees are responsible for obtaining prior 
authorization from the Plan for out of network services prior to seeking 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 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 outpatient substance abuse rehabilitation provided from January 
8, 2020 to February 19, 2020.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to waive the copayment for a colonoscopy performed on March 9, 2020. 
 
You asked the Plan to waive the copayment for a colonoscopy. You say that you received a screening 
colonoscopy with no polyps removed. The Plan denied your request. The Plan says that the correct copayment 
was applied. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not obtain and forward to us medical records showing whether 
polyps were biopsied or removed on March 9, 2020. There is insufficient documentation in the case record to 
support the Plan's assertion that the service rendered to you was a diagnostic and not a screening colonoscopy. 
It is the burden of the Medicare Health Plan to substantiate the denial with medical evidence. Therefore, we 
decided that the Plan has to waive the copayment for a colonoscopy performed on March 9, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee on February 18, 
2020. 
 
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied 
your request. The Plan says prior authorization was not obtained by the provider or facility. 
 
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 to the enrollee on 
February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on January 27, 2020. 
 
You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says genetic testing 
requires 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 
genetic testing. 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 genetic testing provided on January 27, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory tests provided on December 12, 2019. 
 
You asked the Plan to pay for the laboratory tests. You submitted medical records for review. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
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 laboratory tests provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 25, 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 
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 physician's services provided on March 25, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on February 4, 2020. 
 
You asked the Plan to pay for drug testing. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for this testing is correct, because the documentation submitted 
does not support a valid order for this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or 
clear intent to order the specific lab services billed on this claim. Based on this information, we decided that 
Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not 
have to pay for drug testing provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on January 24, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
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. 
 
We find that CPT codes80157, 80159, 80162, 80173, 80177, and 80201 are not supported in the medical 
record. The testing at issue is performed on a blood sample. The records do not indicate that a blood sample 
was obtained from the enrollee for the testing services. 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 lab 
services provided on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intermittent limb compression device provided to the 
enrollee October 11, 2019. 
 
You asked the Plan to pay for the intermittent compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says the Delivery Ticket submitted did not include the carrier's tracking 
number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket 
submitted. 
 
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.  
 
The record does not contain a valid proof of delivery for the supplies provided in this case. The delivery ticket 
did not include any tracking number to tie it to the proof of delivery, so the billed services cannot be verified. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device provided 
to the enrollee October 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a 
participating provider on February 5, 2020. 
 
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not agree with 
these charges. 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 outpatient surgery/in-network/surgery services.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an outpatient surgery. The total 
allowed amount is $3,083.86. The total amount you are being asked to pay is $616.77 ($3,083.86 x 20% = 
$616.77). An outpatient surgery falls within the outpatient surgery/in-network/surgery 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 coinsurance for an outpatient surgery provided by a 
participating provider on February 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for amounts you feel you paid over your maximum 
out-of-pocket limit up until August 2019. 
 
You asked the Plan to reimburse you for amounts you feel you paid over your maximum out-of-pocket limit. 
You say that you paid more than your maximum out-of-pocket amount. The Plan denied your request. The Plan 
says the cost share at issue was included in your 2019 out-of-pocket break down and you did not exceed your 
maximum. 
 
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 your in-network 
maximum out-of-pocket amount is $2800. 
 
The item or service you asked the Plan to reimburse you for falls within the benefit category- understanding 
your out-of-pocket costs for covered services. The Plan has followed Medicare rules by clearly disclosing in 
the contract that your in-network maximum out-of-pocket amount is $2800. The record shows you did not pay 
over the maximum outlined in your 2019 Evidence of Coverage. Therefore, we decided that the Plan does not 
have to reimburse you for amounts you feel exceeded your maximum out-of-pocket limit up until August 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on 
February 21, 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 diagnosis is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 these services. Our reviewer says that the 
services were not medically necessary. Our physician reviewer found the enrollee appears to have metastatic 
right lung cancer based on the PET scan and ICD-10 code provided. No records other than a PET scan from 
February 21, 2020 are provided to indicate a rationale for a PET scan. The service is not reasonable or 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the positron emission tomography (PET) scan rendered on February 21, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on December 2, 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 procedure code 85025 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 85025 is blood count; complete (CBC), automated (Hgb, 
Hct, RBC, WBC and platelet count) and automated differential WBC count. 
 
We find that CPT code 85025 is not supported in the medical record. Specifically, the records do not show that 
a differential white blood cell count was performed. Based on this information, we decided that Medicare rules 
for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for 
the laboratory services rendered on December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the coinsurance for the hearing aid provided on February 4, 
2020. 
 
You asked the Plan to adjust the coinsurance for the hearing aid. You say that your coinsurance is $250 too 
much. The Plan denied your request. The Plan says you pay 25% coinsurance of the allowed amount and any 
amount over $1000 for the out-of-network provider service. 
 
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 25% 
coinsurance and any amount over $1000 for Mandatory Supplemental Hearing Aid Benefit, out-of-network.  
 
You have been asked to pay 25% coinsurance and any amount over $1000 for the hearing aid. The hearing aid 
falls within the Mandatory Supplemental Hearing Aid Benefit category. The supplier is out-of-network. 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 coinsurance for the hearing aid provided on February 4, 2020.