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

 
We decided that the Plan does not have to pay for the medical services provided on July 22, 2020 to July 24, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the services provided. You say that you did not know that the provider was not 
participating with your plan. The Plan denied your request. The Plan says you must use network providers to 
get your medical care and 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 services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided on July 22, 2020 to July 24, 2020 by an out of 
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ankle x-ray provided on June 15, 2020. 
 
You asked the Plan to waive the copayment for the ankle x-ray. You say that you were informed there was no 
copayment because this was a scheduled follow up after surgery. 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 $40 
copayment for basic radiological services at an in-network specialist's office, urgent care center, outpatient 
hospital or freestanding radiological facility.  
 
You have been asked to pay $17.77, which is less than the standard $40 copayment for the ankle x-ray. The 
ankle x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. 
There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up 
to a surgical procedure. 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 ankle x-ray provided on June 
15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 27, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service 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 April 27, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient therapy provided from June 1, 
2020, through June 16, 2020. 
 
You asked the Plan to waive the copayment for outpatient therapy. You say that you say that you were trying to 
better yourself not knowing you would be hit with money out-of-pocket. You say that your budget is full. The 
Plan denied your request. The Plan says the copayments 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 each in-network, Medicare-covered therapy visit. 
 
You have been asked to pay a $35 copayment for each outpatient therapy visit. The total amount you owe is 
$175 ($35/ visit x 5 visits = $175). Outpatient therapy falls within the "Outpatient rehabilitation services" 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for outpatient therapy provided from 
June 1, 2020, through June 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the four additional intraoral periapical x-rays provided on 
June 1, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-rays. You say that you were advised that 
your insurance was accepted. You also say that you are on a fixed income, and had no way of knowing the 
services would not be covered. The Plan denied your request. The Plan says the frequency for this benefit has 
been exhausted. 
 
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, intraoral x-rays are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on June 1, 
2020, and your intraoral x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pay for the four additional intraoral periapical x-rays provided on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visits provided on April 9, 2019 
and October 31, 2019 and fundus photography, visual field exam, eye evaluation, refractive state determination 
and eye exam provided on March 4, 2020. 
 
You asked the Plan to waive the deductible for the office visits, fundus photography, visual field exam, eye 
evaluation, refractive state determination and eye exam. You say that anytime you went to your previous doctor 
you always paid a $25 or $35 copayment. You say that it is unreasonable to assume your out-of-pocket cost 
would be the maximum. The Plan denied your request. The Plan says the deductible applied correctly. 
 
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 your annual deductible for 2019 was $300 and your annual deductible for 2020 
is $350. This is the amount you have to pay out-of-pocket before the Plan will pay its share for your covered 
Medicare Part A and Part B services. 
 
The item or service you asked the Plan to waive the deductible for fall within the "Physician/Practitioner 
services, including doctor?s office visits" and "Vision care" benefit category. The Plan has followed Medicare 
rules by clearly disclosing in the contract that your annual deductible applies to all services except preventive 
services, emergency room visits, emergency ambulance, urgent care and applicable riders.  
 
This cost sharing is a contractual obligation that had not been met at the time the office visits, fundus 
photography, visual field exam, eye evaluation, refractive state determination and eye exam were received on 
April 9, 2019, October 31, 2019 and March 4, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for the office visits provided on April 9, 2019 and October 31, 2019 and fundus 
photography, visual field exam, eye evaluation, refractive state determination and eye exam provided on March 
4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transportation service 
(A0429) provided on February 20, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 
copayment for each one-way Medicare-covered ground ambulance trip.  
 
You have been asked to pay a $225 copayment for the one-way Medicare-covered ground ambulance trip 
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0429) 
provided on February 20, 2020.  
 
Your complaint about being asked to pay for two ambulance transports provided in order to achieve your 
original required destination is not a valid appeal for medical coverage. This part of your complaint is a 
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types 
of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care clinic visit (99202) on May 
19, 2020. 
 
You asked the Plan to waive the copayment for an urgent care clinic visit. You say that your understanding was 
that all tests relating to the COVID-19 virus were covered under your insurance without out-of-pocket costs. 
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 $40 
copayment for each urgently needed visit in a non-contracted Urgent Care Center or walk-in clinic.  
 
The Plan has documented in the case record that its cost-sharing relief policies related to the COVID-19 
pandemic do not include a waiver for copayments related emergency, urgent and ambulance services. You have 
been asked to pay a $40 copayment for an urgent care clinic visit. An urgent care clinic visit falls within the 
"Urgently Needed Services" benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an urgent 
care clinic visit (99202) on May 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on June 3, 
2020. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you don't understand the 
option for an outpatient or clinic visit. You say that you always make an appointment in advance and don't 
understand the difference. 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 $40 
copayment for lab services at an in-network outpatient hospital.  
 
You have been asked to pay a $40 copayment for the laboratory services. Laboratory services falls within the 
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the 
laboratory services were provided by the hospital. 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 services provided on June 3, 2020.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services provided on March 5, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were 
billed incorrectly. 
 
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 contends that the services should have been billed on the same claim. 
However, Medicare rules state the more than ambulance service may be reported on the same claim, but does 
not mandate this. More than one ambulance service provided on the same date may also be reported on separate 
claims. The Plan has not provided documentation substantiating its denial. Therefore, we decided that the Plan 
has to pay for the ambulance services provided on March 5, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the manual therapy techniques (97140), 
self-care management training (97535), and the therapeutic exercises (97110) provided from January 3, 2020, 
through February 17, 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 services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 
copayment for each Medicare-covered physical therapy, speech language therapy, and occupational therapy 
visit.  
 
You have been asked to pay $140 ($20 copayment x 7 visits) for the outpatient therapy services provided. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the manual therapy techniques (97140), self-care 
management training (97535), and the therapeutic exercises (97110) provided from January 3, 2020, through 
February 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic injection and glucose test by a glucometer 
provided on November 19, 2019 billed with codes 82962 and 96372. 
 
You asked the Plan to pay for . You say that all billed codes are supported by the record and should be paid. 
The Plan denied your request. The Plan says these codes are 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 82962 is Glucose, blood by glucose monitoring device(s) 
cleared by the FDA specifically for home use. The definition of 96372 is Therapeutic, prophylactic, or 
diagnostic injection (specify substance or drug); subcutaneous or intramuscular. 
 
We find that these codes are not supported in the medical record. Specifically, the progress note does not 
document any type of injection being performed on this date of service and there is no notation of any blood 
glucose level being tested. Based on this information, we decided that Medicare rules for coverage of  have not 
been met. Therefore, we decided that the Plan does not have to pay for the therapeutic injection and glucose 
test by a glucometer provided on November 19, 2019 billed with codes 82962 and 96372.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. You are consistently ambulating more than 100 feet 
and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not 
required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at 
this point are custodial and, as a practical matter, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is generally medically stable with debility from acute illness with no 
evidence of medical or nursing needs in an IRF and her current functional status does not require IRF level of 
therapies. There is no evidence of medical issues that require monitoring by an inpatient rehab physician three 
times a week. The documentation does not support that there is a need for an intensive therapy program with 3 
hours a day at current level of function and an interdisciplinary approach to rehab care. The enrollee is not 
expected to make a significant functional recovery in an IRF at the current pace. The enrollee's rehab needs can 
be safely and effectively met in an alternate, less intense setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar
approach) for decompression of neural elements, (with or without ligamentous resection, discectomy,
facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single
or multiple levels, unilateral or bilateral; lumbar (CPT Code 0275T).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the type of service requested is not supported because research has not found it to be
helpful for the enrollee's condition or for what is causing their pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the MILD procedure remains experimental. More research is needed to show safety and
efficacy of the procedure. It is not medically needed, It is not the care standard.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve (CPT Code 0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a grab bar and shower chair. 
 
You asked the Plan to pre-approve a grab bar and shower chair. You say that you are concerned with falling 
and hitting your head due to weakness in your legs. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars and shower chairs are not 
covered because they are not primarily medical in nature.  
 
While a grab bar and shower chair may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar and shower 
chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that due to your surgery and not leaving 
your home to buy these supplies because of the COVID pandemic. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.