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

We decided that the Plan does not have to pay for the drug testing services provided on March 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist visits rendered from February 17, 2020 to March 30, 2020.You asked the Plan to waive the copayments forthese services. You say that you were in the doctor's office for one to two minutes.The Plan denied your request. The Plan says the copayments were 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 $35 copayment for services obtained from a specialist. Review of the file shows that you had six specialist visits from February 17, 2020 to March 30, 2020. You have been asked to pay a $35 copayment per date of service for these services, for a total of $210. These services fall within the services obtained from a specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe specialist visits rendered from February 17, 2020 to March 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit provided on October 2, 2019 by an 
OON provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you were not aware than an authorization 
was required for an outpatient office visit. The Plan denied your request. The Plan says the treating provider is 
a non-network provider who does not work with the enrollee's health plan. The Plan also says that the enrollee 
self-directed for 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 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 outpatient office visit provided on October 2, 
2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided on 
June 3, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the services were processed 
correctly per your plan benefits. 
 
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 for outpatient surgery received in an outpatient hospital setting.  
 
You have been asked to pay a $250 copayment for the outpatient surgery services. The outpatient surgery 
services fall within the outpatient surgery 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 outpatient surgery services provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine you received on July 7, 2020. 
 
You asked the Plan to pay for the vaccine. You say that you were told this vaccine would be covered. The Plan 
denied your request. The Plan says this is not a covered service. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The 
Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the vaccine. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the eyewear provided on June 11, 2020.
You asked the Plan to pay additionally for the eyewear. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the retail value of your glasses was $454 and the $200 balance was applied to the retail value of the glasses per your contract with the Plan. The Plan says that leaves you a balance of $254 that you are responsible for. The Plan says that you stated you already paid $68 towards this balance, which leaves you with a $186 total amount left as your responsibility.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The Plan's contract clearly has a $200 allowance for supplemental eyewear. The file shows that the Plan paid the full $200 amount towards your eyewear and you are responsible for the remaining amount due. Therefore, we decided that the Plan does not have to pay additionally for the eyewear provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required and two 
localized deliveries of antimicrobial agents provided on May 18, 2020. 
 
You asked the Plan to pay for the core buildup and localized deliveries of antimicrobial agents. You say that a 
plan representative referred you to this provider. The Plan denied your request. The Plan says these 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 core 
buildup, including any pins when required and two localized deliveries of antimicrobial agents provided on 
May 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the specialist services provided on June 11, 
2020. 
 
You asked the Plan to waive the copayment for the specialist services. You say that this was not a specialist 
visit and you have never been charged in the past. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
According to the medical records received, you were seen on June 11th, 2020 for a suprapubic catheter change. 
The records show that the original catheter was drained and replaced without complications. According to your 
health plan benefit, you are covered for physician/specialist office visits, however, specialists office visits have 
a higher copayment amount of $50 per 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 
specialist services provided on June 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from 
February 9, 2020, through February 14, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not provided 
with the services you needed and are not responsible for the inpatient cost-share. The Plan denied your request. 
The Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
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 EOC states, you pay $200 each day for days 1-8 of a covered inpatient stay during a benefit period. You 
pay $0 each day for days 9-90 of a covered inpatient stay during a benefit period. There is a $1,600 maximum 
out-of-pocket limit per benefit period.  
 
 
 
 
The first hospitalization claim paid based on DRG 208 and applied $200 per day for days 1-4 of the benefit 
period. The second hospitalization claim paid based on DRG 306 and applied $200 per day for days 5-8 of the 
benefit period which satisfied the $1,600 maximum out-of-pocket limit per benefit period. No cost share was 
applied beyond day 8 of the benefit period. Your medical records clearly show inpatient services were 
rendered. 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 inpatient hospital care provided from February 
9, 2020, through February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided by a 
non-network provider. 
 
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 were rendered by a non-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 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 provided by a non-network
 provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (Q5001, G0299, G0151, & G0152) 
provided November 7, 2019 to December 13, 2019. 
 
You asked the Plan to pay for the home health services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was not filed correctly. 
 
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 codes Q5001, G0299, G0151, & G0152 are not supported in the medical record. Specifically, 
the claim included an invalid HIPPS code billed for the dates of service. Based on this information, we decided 
that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the 
Plan does not have to pay for home health services (Q5001, G0299, G0151, & G0152) provided November 7, 
2019 to December 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided from January 21, 2020, 
through January 29, 2020. 
 
You asked the Plan to pay for the psychotherapy services. You say that the Plan denied your request. The Plan 
says non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan 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 psychotherapy services provided from January 21, 
2020, through January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on May 11, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollees 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 a lumbar-sacral orthosis 
(L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on May 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 12, 2020. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 June 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses as defined by codes L3170-RT-KX, L1971-RT-
KX, L1851-RT-KX, L2397-RT-KX, L0650, L1851-LT-KX, L2397-LT-KX, L3170-LT-KX provided to the 
enrollee on March 2, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are 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 orthoses as defined by codes L3170-RT-KX, 
L1971-RT-KX, L1851-RT-KX, L2397-RT-KX, L0650, L1851-LT-KX, L2397-LT-KX, L3170-LT-KX 
provided to the enrollee on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for moderate sedation services (G0500) provided on February 
18, 2020. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did 
not include not include a detailed procedure report for this service. 
 
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 G0500 is moderate sedation services provided by the 
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 
years or older (additional time may be reported with 99153, as appropriate). 
 
We asked our coder 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 the moderate sedation services. Our reviewer says that CPT 
code G0500 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
procedure report documents that a consent was signed, no documentation of procedure was noted.  Procedure 
report documents under Plan, #3 Notes "pending",  and plan for Moderate Sedation, however, no 
documentation submitted to verify that Moderate Sedation and a independent trained observer to assist in the 
monitoring of the patients level of consciousness and physiological status was performed on this date of 
service. 
 
 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that 
the Plan does not have to pay for moderate sedation services (G0500) provided on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from 
December 15, 2019, to December 28, 2019. 
 
You asked the Plan to waive the copayment for inpatient stay. You say that the enrollee's estate is insolvent, 
and you are not responsible for the balance of this debt. The Plan denied your request. The Plan says the 
copayment amount the enrollee has been charged 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay $300 copayment per day for days 1 to 5 and $0 copayment for additional days for in-network 
inpatient stay. This inpatient stay lasted 13 days, resulting in a copayment amount of $1,500. 
 
The enrollee has been asked to pay $300 copayment per day for days 1 to 5 and $0 copayment for additional 
days for inpatient stay. Inpatient stay falls within the Inpatient Hospital Care benefit category. This means that 
the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a 
contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for an inpatient hospital stay provided from December 15, 2019, to 
December 28, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for outpatient services (A4657, 82040, 82310, 84100, 84295, 85018, 
85025, 85041, 55513, J0606, J2501, 90999) provided from December 7, 2019, to January 30, 2020. 
 
You asked the Plan to pay for outpatient services. You say that this should be covered. The Plan denied your 
request. The Plan says that the Plan is the secondary payer. 
 
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. Though the Plan states they are the secondary payer for the claims at issue, they 
have not included any information about the primary payer or the coordination of benefits. The enrollee is not 
listed as having a different primary insurance for the dates at issue. Therefore, we decided that the Plan has to 
pay for outpatient services (A4657, 82040, 82310, 84100, 84295, 85018, 85025, 85041, 55513, J0606, J2501, 
90999) provided from December 7, 2019, to January 30, 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.