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

We decided that the Plan does not have to pay for the surgical services (15630, 14040) provided on July 2, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the surgical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider; therefore, payment has been correctly denied. 
 
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 surgical services (15630, 14040) provided on 
July 2, 2020, by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for wound repair provided on April 30, 2020. 
 
You asked the Plan to waive the deductible for wound repair. You say that you did not know that the provider 
was out-of-network. 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 $750 deductible for out-of-network services. Your contract with the 
Plan also clearly says that once the $750 deductible has been met, you must pay 40% coinsurance for out-of-
network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers. 
 
You received wound repair on April 30, 2020. The record shows that you had paid $104.57 toward the $750 
deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible 
balance of $645.43. Now that the $750 deductible has been met, you are also responsible to pay 40% 
coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. 
$977.22 (allowed amount) - $645.43 (deductible amount) = $331.79 and 40% of that is $132.72.  
 
The total amount you owe is: $778.15. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-
network outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers. This cost sharing is a contractual obligation that had not been met at the time wound repair was 
 
 
received on April 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
wound repair provided on April 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the physical therapy (PT) visit you had on 
August 21, 2020. 
 
You asked the Plan to waive the copayment for the PT visit. You say that if you had known there would be a 
cost to you, you would not have had the PT service. 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 $35 
copayment for therapy visits.  
 
You have been asked to pay a $35 copayment for the PT 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 physical therapy (PT) visit you had on August 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you 
received from June 4, 2020, to July 30, 2020 at an outpatient hospital facility. 
 
You asked the Plan to waive the copayments for the PT services. You say that you were never told that you 
would owe these copayments. The Plan denied your request. The Plan says you were charged these copayments 
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 $40 
copayment for outpatient rehabilitation services at an outpatient hospital facility.  
 
You have been asked to pay a $40 copayment for the PT services. The PT services fall within the outpatient 
rehabilitation services at an outpatient hospital facility. 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 copayments for physical therapy (PT) services you received from June 4, 2020, to July 30, 2020 at an 
outpatient hospital facility.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does 
not have to waive the copayment for the administration provided on May 21, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment 
for the administration. You say that you disagree with how the claim was billed because it resulted in the Plan 
not covering 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 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers. 
 
You received a Medicare Part B drug injection on May 21, 2020. The allowed amount is $1,987.50 and 20% of 
that is $397.50. You are also responsible to pay the total allowed amount of $93.25, which is less than the 
copayment amount, for the administration. The total amount you owe is: $490.75.   
 
 
 
You have been asked to pay the total amount of $490.75 for a Medicare Part B drug injection and the 
administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit 
category. The administration falls within the outpatient surgery and other medical services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 injection and does not have to waive the copayment for the 
administration provided on May 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does 
not have to waive the copayment for the administration provided on August 8, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment 
for the administration. You say that you disagree with how the claim was billed because it resulted in the Plan 
not covering 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 20% 
coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must 
pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient 
facilities and ambulatory surgical centers. 
 
You received a Medicare Part B drug injection on August 8, 2020. The allowed amount is $2,048.35 and 20% 
of that is $409.67. You are also responsible to pay the total allowed amount of $244. 47, which is less than the 
copayment amount, for the administration. The total amount you owe is: $654.14.   
 
You have been asked to pay the total amount of $654.14 for a Medicare Part B drug injection and the 
administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit 
category. The administration falls within the outpatient surgery and other medical services provided at hospital 
outpatient facilities and ambulatory surgical centers 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 injection and does not have to waive the copayment for the 
administration provided on August 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an out-of-network provider office visit 
(99214) on March 3, 2020. 
 
You asked the Plan to waive the copayment for an out-of-network provider office visit. You say that this 
service was rendered by an in-network provider. The Plan denied your request. The Plan says the correct 
copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for services obtained out-of-network from a primary care provider.  
 
The Plan has documented that the services were rendered by an out-of-network provider. You have been asked 
to pay a $20 copayment for an out-of-network provider office visit. An out-of-network provider 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 out-of-network provider office visit (99214) on March 3, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injection (J3490) provided on March 4, 
2020. 
 
You asked the Plan to waive the coinsurance for injection. You say that you should not be responsible for the 
cost share. The Plan denied your request. The Plan says the cost share is correct. 
 
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 Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for injection. This service 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 injection (J3490) 
provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory tests provided on August 14, 
2020. 
 
You asked the Plan to waive the copayment for laboratory tests. You say that you were told that you would not 
owe a copayment if you had the labs taken the same day as an office visit. 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 $10 
copayment for laboratory tests.  
 
You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall within the outpatient 
diagnostic tests and therapeutic services and supplies 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 laboratory tests provided on August 14, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS). 
 
You asked the Plan to pre-approve the requested services. You say that the device can detect changes in 
extracellular fluid. The Plan denied your request. The Plan says that the effectiveness of the procedure cannot 
be established in verified medical literature. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pre-approve the requested services. Our physician 
reviewer found that bioimpedance spectroscopy is used to assess lymphedema by measuring limb fluid content 
as an electric current passes through cell membranes and tissues. It is used for diagnosis as well as assessing 
treatment response. It is an increasingly utilized diagnostic technique that allows for the subclinical detection of 
breast cancer-related lymphedema, prior to clinically evident disease. Early detection allows early treatment for 
prevention of clinically significant lymphedema. It has become a standard of care. Therefore, the service is 
reasonable and 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 the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve bioimpedance spectroscopy (BIS).  
 
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 waive the coinsurance for the dialysis services (J1270, J1644, 
A4657, Q4081) provided February 3, 2020 to August 31, 2020 
 
You asked the Plan to waive the coinsurance for the dialysis services. You say that you feel the treatment 
should be fully covered. The Plan denied your request. The Plan says the copayment applied correctly in this 
case. 
 
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 Medicare-covered renal dialysis. 
 
You have been asked to pay a total cost share amount of $5292 ($705.60 + $705.60 + $764.40 + $764.40 + 
$764.40 + $764.40 + $823.20 + 764.40). Each of these cost share amounts was totaled with the 20% 
coinsurance that for the services provided which fall within the Medicare-covered renal dialysis 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 the dialysis services (J1270, J1644, A4657, 
Q4081) provided February 3, 2020 to August 31, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on July 20, 2020. 
 
You asked the Plan to pay for the foot orthotics. You say that the lift has helped your balance and walking. The 
Plan denied your request. The Plan says this item is not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records do not show that you suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on July 20, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any 
type (CPT Code E2300). 
 
You asked the Plan to pre-approve the seat elevator. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the seat elevator does not serve a primary medical 
purpose and is statutorily non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any type 
(CPT Code E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0482, 80307) provided on June 25, 
2020, by an out of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or 
the provider; therefore, payment has been correctly denied. 
 
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 laboratory services (G0482, 80307) provided 
on June 25, 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 physician services provided on March 6, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 physician services provided on March 6, 2020 by 
an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
September 20, 2019 to September 30, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
 
 
 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the claims 
were not initially billed under a UB-04 in order to establish the required HHA reports on the 0023 revenue code 
line the date of the first covered visit provided during the initial episode; therefore, the Medicare rule for 
payment of this claim has not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided to the enrollee from September 20, 2019 to September 30, 2019.