Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for refraction services (92015) provided
January 29, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you and your husband had the
same eye exam with the same doctor but was charged differently. He is billed routine vision exam and yours is
billed as other medical services. The Plan denied your request. The Plan says the copayment was applied
correctly per the 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 $35
copay for each Medicare covered exam to diagnose and treat diseases and conditions of the eye.
You have been asked to pay $35 copay for the vision services. The vision services fall within the Vision care
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for refraction services (92015)
provided January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on December 5, 2019.
You asked the Plan to pay for the services. You say that The Plan denied your request. The Plan says
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were 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 drug testing services provided to the enrollee on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospice care provided to the enrollee from June 1,
2019 through June 30, 2019.
You asked the Plan to pay for inpatient hospice care. You say that the claim should be paid. The Plan denied
your request. The Plan says while the enrollee is in the hospice program, the hospice provider will bill Original
Medicare for the services that Original Medicare pays for.
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 inpatient hospice care provided to the enrollee from June 1,
2019 through June 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from December 25, 2019 through January 3, 2020.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from December 25, 2019 through January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided to the enrollee on
February 27, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share
responsibility for the services you received. 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).
Review of the file show that you received the DME on February 27, 2020. You are asked to pay 20%
coinsurance for the DME. 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 coinsurance for the DME provided to
the enrollee on February 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient heart surgery.
You asked the Plan to pre-approve inpatient heart surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 inpatient heart surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has some coronary risk and chest pain but there is no objective evidence of ischemia by electrocardiogram, troponin values or stress testing. In addition, the computed tomography (CT) angiogram reports only moderate stenosis of one vessel (RCA) that is not flow limiting by fractional flow reserve (FFR). Therefore, the documentation provided does not support the medical necessity for coronary artery bypass surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient heart surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient heart surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Mohs procedure provided on February
6, 2020.
You asked the Plan to waive the copayment for the Mohs procedure. You say that your previous visits never
resulted in a fee. You say that this could be a coding error. 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 $300
copayment for all other outpatient services not provided in an ambulatory surgical center.
You have been asked to pay a $300 copayment for the Mohs procedure. The Mohs procedure falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The records show that the Mohs procedure was billed 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 the Mohs procedure provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 29, 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 January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for personal care assistant services provided from October 21,
2019 to October 23, 2019.
You asked the Plan to pay for personal care assistant services. You say that you were instructed to resume
services until October 31, 2019. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because these services are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that custodial care services such as personal care
attendant services are not covered by Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of personal care assistant services have not been met. Therefore, we decided that the Plan does not
have to pay for personal care assistant services provided from October 21, 2019 to October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair, detachable arms, desk or full length, swing away detachable footrests (E1140), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The requested billing code (E1140) is not approved by Medicare. The requested code is only used in some cases for maintenance and service. The enrollee's nurse practitioner sent more information that describes the enrollee's need for the wheelchair and that they live in a care facility. However, there is no assessment of the enrollee's ability to use a wheelchair. There is no assessment of a caregiver's ability to move the enrollee in the wheelchair. This information and a correct billing code should be included with a new wheelchair request, if needed. Therefore, we decided that the Plan does not have to pre-approve wheelchair, detachable arms, desk or full length, swing away detachable footrests (E1140), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit that you provided on
November 6, 2019, December 4, 2019 and December 11, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. 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
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 a domiciliary, rest home visit that you provided on November 6,
2019, December 4, 2019 and December 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B chemotherapy drug and it's administration provided on October 7, 2019.
You asked the Plan to waive the coinsurance for the Part B chemotherapy drug and its administration. You say that there was a mix-up with the codes used on this specific date. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 each Medicare-covered chemotherapy drugs and the administration of that drug. You have been asked to pay a total of $1,650.00 for the Part B chemotherapy drug and its administration. The Part B chemotherapy drug and its administration falls within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
October 7, 2019
Chemotherapy drug administration
$151.69
20%
$30.34
October 7, 2019
Chemotherapy drug
$20,743.20
20%
$1,619.66 - This is less than the standard amount because you met your maximum out-of-pocket amount.
Total
$1,650.00
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 Part B chemotherapy drug and its administration provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 2, 2020.
You asked the Plan to pay for the physician's services. You say that you were not aware that you needed
authorization for this eye exam. The Plan denied your request. The Plan says you must receive care from innetwork
providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's
service area or if the care cannot be provided with an in-network provider, which requires prior authorization
from the plan.
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 physician's services provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 30, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the provider failed to obtain 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 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 physician's services provided on January 30, 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 by an out-ofnetwork
provider from January 9, 2020, to February 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 to the enrollee by an out-of-network provider
from January 9, 2020, to February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased January 17, 2020 from an out-ofnetwork
provider.
You asked the Plan to pay for the hearing aids. You say that a plan representative told you that you would be
reimbursed no matter if in-network or out-of-network. You were never told that the provider needed to be
contracted with the plan. The Plan denied your request. The Plan says hearing aids ordered through provider's
other than the network hearing vendors are not covered.
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 purchased from an in-network provider.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for
the hearing aids purchased January 17, 2020 from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 6, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was a follow up visit for gallbladder surgery. You say that you shouldn't be responsible for the copayment. 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 $45 copayment per specialist visit. You have been asked to pay $44.42, which is less than the standard $45 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a joint injection provided on January 30,
2020.
You asked the Plan to waive the copayment for a joint injection. You say that you are being charged a facility
fee and disagree with the charges because you did not receive a surgery, only an injection and an X-ray. 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 $200
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You received a joint injection on January 30, 2020. A joint injection is considered an outpatient surgical
procedure. Therefore, you are responsible to pay the $200 copayment.
You have been asked to pay a $200 copayment for a joint injection. A joint injection falls within the outpatient
surgery, including 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 copayment for a joint injection provided on January 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on January 2, 2020.
You asked the Plan to waive the copayment for the echocardiography. You say that last year it cost less. You say that the copayment is way too high. 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 $110 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a $110 copayment for the echocardiography. The echocardiography falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The echocardiography is considered an ultrasound. 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 echocardiography provided on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on February 6, 2020.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the knee orthosis (L1851) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960). You say that the Plan should pay this claim. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Review of claims history for this member, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650), the knee orthosis (L1851) and suspension sleeve (L2397), and the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, the knee orthosis and suspension sleeve, and the shoulder-elbow-wrist-hand orthosis provided on February 6, 2020.