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

 
We decided that the Plan does not have to waive the coinsurance for the OnabotulinumtoxinA injection 
provided on May 26, 2020. 
 
You asked the Plan to waive the coinsurance for the OnabotulinumtoxinA injection (J0585). You say that you 
cannot afford the coinsurance. The Plan denied your request. The Plan says you were charged this coinsurance 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for the OnabotulinumtoxinA injection (J0585). The 
OnabotulinumtoxinA injection (J0585) 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 the OnabotulinumtoxinA injection provided on May 26, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on July 3, 2019. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says that 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 nurse practitioner services provided on July 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment defined by codes L1971, 
L3171, L3960, L3916) provided to the enrollee on March 16, 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 there were no valid itemized shipping/billing invoice or proof of delivery for the billed 
date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery to support medical necessity for the supplies provided in 
this case. There is no itemized billing invoice. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
durable medical equipment defined by codes L1971, L3171, L3960, L3916) provided to the enrollee on March 
16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided 
from April 10, 2020 to April 30, 2020. 
 
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you disagree 
with the charges because you feel that the skilled nursing facility benefit category should apply instead. The 
Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $30 copayment for outpatient rehabilitation services.  
 
The medical records show that the enrollee received outpatient rehabilitation services from April 10, 2020 to 
April 30, 2020 for a total of 15 visits. Therefore, the enrollee is responsible to pay a $30 copayment per each 
visit. The total amount you owe is: $30 (copayment) x 15 (outpatient rehabilitation services) = $450.  
 
The enrollee has been asked to pay the total copayment amount of $450 for outpatient rehabilitation services. 
Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments for outpatient rehabilitation services provided from April 10, 2020 
to April 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on March 
27, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not have the 
option of getting to the hospital by car so you should not have to pay. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 $275 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $275 for these 
services. 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 services provided on March 27, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 80050) you received on February 4, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
service. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee 
Schedule indicates that the code in question is non-covered.  
 
We looked at the file and Medicare rules. CPT code 80050 is assigned a status indicator of "N" under the 
Physician Fee Schedule, which means that this code, and the corresponding services, are not covered by 
Medicare or the Plan. 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 services (CPT 80050) you 
received on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on March 3, 2020 through 
March 18, 2020. 
 
You asked the Plan to pay for the outpatient services.. You say that you would like reconsideration because 
these services have been reimbursed before. The Plan denied your request. The Plan says this provider is not 
eligible for Medicare and is registered on the Medicare Opt-Out list. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the outpatient services provided on March 3, 2020 through March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 26, 
2020 through March 13, 2020. 
 
You asked the Plan to pay for acute inpatient hospital 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the records do not show that at the time of inpatient admission, the admitting 
physician expected the patient to require at least two (2) midnights of hospital care. The patient could have 
been monitored and been advised or arranged for placement and other community services under observation 
status. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from February 26, 2020 through March 
13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a wrist-hand orthosis with sleeve (L3916, L2397) provided 
to the enrollee on March 26, 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 enrollee has previously received the same supplies within the 5-year RUL. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical 
equipment is no less than five years. Replacement equipment may be granted when irreparable wear or 
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.  
 
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the 
enrollee has received the same durable medical equipment on March 6, 2020.  These orthoses are still within 
the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn, 
irreparably damaged, or that the enrollee had a change in medical condition to warrant the orthoses at issue.  
Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. 
Therefore, we decided that the Plan does not have to pay for a wrist-hand orthosis with sleeve (L3916, L2397) 
provided to the enrollee on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on January 14, 2020. 
 
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the documentation submitted 
does not include a valid physician order, lab requisition, or medical records to support the codes billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $275 copayment charged for ambulance transport 
provided on March 10, 2020. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement. 
 
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 $275 
copayment for ambulance transport. 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 $275 copayment charged for ambulance 
transport provided on March 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses defined by codes L3960, L0650, L1851, L2397 
provided to the enrollee on February 5, 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. The rules state that DMEPOS is covered only when the patient's medical 
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the 
type and quantity of items ordered and for the frequency of use.  
 
The record shows that documentation submitted did not indicate the provider discussed the need for the billed 
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to 
pay for the orthoses defined by codes L3960, L0650, L1851, L2397 provided to the enrollee on February 5, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided to the enrollee on January 28, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the services billed are not related to manual manipulation of the spine. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided to the enrollee on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for annual gynecological examination (CPT Code S0612) 
provided on June 5, 2020. 
 
You asked the Plan to pay for the annual gynecological examination. You say that you are appealing for 
reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your benefit 
for this service. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of the annual gynecological examination have not been met. You had this same exact service on 
February 21, 2019. Your EOC states, "for all women: Pap tests and pelvic exams are covered once every 
twenty-four (24) months." Therefore, we decided that the Plan does not have to pay for annual gynecological 
examination (CPT Code S0612) provided on June 5, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on March 27, 2020. 
 
You asked the Plan to waive the copayment for lab services. You say that you have never been charged in the 
past and disagree with 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 a $50 
copayment for lab services provided in an outpatient hospital facility. 
 
You received lab services at an outpatient hospital facility on March 27, 2020. Therefore, you are responsible 
to pay the $50 copayment.   
 
You have been asked to pay a $50 copayment for lab services. Lab services 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 lab services provided on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for DME provided on February 4, 2020. 
 
You asked the Plan to waive the copayment for DME. You say that you disagree with the charges because the 
device was necessary. 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 DME and related supplies.  
 
You received DME on February 4, 2020. The allowed amount is $306.18 and 20% of that is $61.24.  
 
You have been asked to pay the total coinsurance amount of $61.24 for DME. DME falls within the DME and 
related 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 DME provided on 
February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9338) provided from March 15, 
2020 through March 19, 2020. 
 
You asked the Plan to pay for the services. You say that the claims should be paid. 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 services have not been met. Procedure code S9338 has a status 
code of "I" which is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy (S9338) provided from March 15, 2020 through March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foot exam rendered on January 22, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code G9226 is not payable. 
 
The Plan must follow Medicare rules. The rules say that codes with a status indicator of M are measurement 
codes used for reporting purposes only. 
 
We looked at the file and Medicare rules. The provider submitted a claim for procedure code G9226. This code 
has a status indicator of M and is not payable under Medicare. Therefore, we decided that the Plan does not 
have to pay for the foot exam rendered on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care 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 
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 April 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 23, 2020 by an 
OON provider. 
 
You asked the Plan to pay for the medical services. You say that the claims should be paid. The Plan denied 
your request. The Plan says the member self-referred to this non-participating provider and the medical records 
do not reveal any medically urgent or emergent 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 the medical services provided on January 23, 2020 
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 13, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that you are requesting a retroactive authorization. 
The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and 
authorization for certain 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 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 lab services provided on September 13, 2019 by an out of 
network (OON) provider.