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

We decided that the Plan does not have to pay for the outpatient hospital services provided on February 7, 2020 
by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were 
neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 hospital services provided on 
February 7, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 18, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, 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. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from December
12, 2019 to December 27, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the services were
necessary because you live alone and did not have anyone to take care of you. 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 $300
copayment per day for days 1-5 for inpatient hospital care.
You had an inpatient hospital stay from December 12, 2019 to December 27, 2019. Therefore, you are
responsible to pay a $300 copayment for days 1-5 (December 12, 2019 to December 16, 2019). $300
(copayment) x 5 (inpatient days) = $1,500.
You have been asked to pay the total copayment amount of $1,500 for an inpatient hospital stay. An inpatient
hospital stay falls within the inpatient hospital 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 an inpatient hospital stay from December 12, 2019 to December 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an observation stay provided on March 7, 
2020. 
 
You asked the Plan to waive the copayment for an observation stay. You say that you were not admitted to the 
hospital and should only owe an emergency room copayment. 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 $250 
copayment for observation services. 
 
The medical records show that you received observation services on March 7, 2020. Therefore, you are 
responsible to pay the $250 copayment.   
 
You have been asked to pay a $250 copayment for an observation stay. An observation stay falls within the 
outpatient hospital 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 
observation stay provided on March 7, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from February 6, 2020 to 
February 26, 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 the claims were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that home health services must be billed with a valid 
HIPPS code. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the required valid 
HIPPS code. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
February 6, 2020 to February 26, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services provided on January 7, 2020 
through January 10, 2020. 
 
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration 
because the claim has not been paid in full. The Plan denied your request. The Plan says an "always therapy" 
service, CPT code 97161, was billed without a required therapy modifier. 
 
The Plan must follow Medicare rules. Medicare rules say that claim must include GN, GO or GP modifiers to 
distinguish the discipline of the plan of care under which the service is delivered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Specifically, this claim includes a therapy code 
that has been billed without the required therapy modifier. Therefore, we decided that the Plan does not have to 
pay for outpatient hospital services provided on January 7, 2020 through January 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis provided on February 3, 
2020. 
 
You asked the Plan to waive the copayment for arthrocentesis. You say that you feel that the charges are 
outrageous 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 $300 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical centers.  
 
You have been asked to pay a $300 copayment for arthrocentesis. Arthrocentesis falls within the outpatient 
surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis provided on 
February 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99213 provided on February 12, 2020.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. 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 99213 is office or other outpatient visit for the evaluation
and management of an established patient, which requires at least 2 of these 3 key components: An expanded
problem focused history; An expanded problem focused examination; Medical decision making of low
complexity. Counseling and coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or
family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are
spent face-to-face with the patient and/or family.
We find that CPT code 99213 is not supported in the medical record. Specifically, this code was billed in the
place of service 23, Emergency room hospital. This service was billed with the inappropriate place of service.
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit coded 99213 provided on February
12, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency care (99284) provided on 
March 17, 2020. 
 
You asked the Plan to waive the copayment for this service. 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 $90 
copayment for Medicare-covered emergency room visits.  
 
You have been asked to pay a $90 copayment for the emergency care 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 emergency care (99284) provided on March 17, 2020.  
 
Your complaint about not receiving a requested medical service in the emergency room 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME purchased on April 6, 2020 from a non-Medicare 
provider. 
 
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered. 
The Plan denied your request. The Plan says the items were obtained from a provider who is not under contract 
with the health plan and is not certified for Medicare. 
 
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. 
 
Review of the file show that you purchased the DME on April 6, 2020 from a non-Medicare provider. The 
rules say that to receive payment for covered Medicare items or services from either Medicare (in the case of 
an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must 
be enrolled in the Medicare program. 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 DME purchased on 
April 6, 2020 from a non-Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies 
provided on March 6, 2020. 
 
You asked the Plan to waive the coinsurance for prosthetic devices and related supplies. You say that you 
cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for prosthetic devices and related supplies.  
 
You received prosthetic devices and related supplies provided on March 6, 2020. The total allowed amount is 
$204.20 and 20% of that is $40.84.  
 
You have been asked to pay the total coinsurance amount of $40.84 for prosthetic devices and related supplies. 
Prosthetic devices and related supplies fall within the prosthetic devices 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 coinsurance for prosthetic devices and related supplies provided on March 
6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 10, 2020. 
 
You asked the Plan to pay for the laboratory 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 
laboratory 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 laboratory services provided on February 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thoracentesis rendered on February 20, 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 32555 was not billed with the appropriate modifier. 
 
The Plan must follow Medicare rules. The rules say that modifier -58 was established to facilitate billing of 
staged or related surgical procedures done during the postoperative period of the first procedure. 
 
We looked at the file and Medicare rules. The file shows that procedure code 32555 was not billed with the 
required -58 modifier to signify as being part of the global surgical package. Therefore, we decided that the 
Plan does not have to pay for the thoracentesis rendered on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the office visits (99215) provided April 23, 
2019 to November 5, 2019. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 
provided are not a covered benefit as they were rendered by a provider that has opted out of Medicare. 
 
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 issue 
reimbursement for the office visits (99215) provided April 23, 2019 to November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not be liable 
for the ambulance services. 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 $250 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $250 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.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 18, 2020. 
 
You asked the Plan to pay for the services provided. You say that toxicology testing is used to assess risk and 
minimize the high cost of adverse outcomes. The Plan denied your request. The Plan says the explanation of 
benefits from the enrollee's primary insurance company is needed. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan 
cannot be held responsible for the services provided until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 18, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the laryngoscopy with biopsy provided on 
March 2, 2020. 
 
You asked the Plan to waive the coinsurance for the laryngoscopy with biopsy. You say that you say that the 
amount you are being asked to pay is too high. 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 out-of-network outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers.  
 
You have been asked to pay $524.09 which is 20% of the allowed amount for the laryngoscopy with biopsy. 
The allowed amount is $2,620.45. ($2,620.45 x 20% = $524.09). The laryngoscopy with biopsy falls within the 
?Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers? benefit category. The record shows the provider is out-of-network.  
 
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 laryngoscopy with biopsy provided on March 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from March 
4, 2020 through March 5, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that the stay was medically necessary. The Plan 
denied your request. The Plan says the facility did not make any attempts to transfer the member to a 
participating facility while in the service area once the member was stable. 
 
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. 
 
Prior approval was not obtained for the hospital admission. 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 inpatient 
hospital care provided to the enrollee from March 4, 2020 through March 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 11, 2020 to January 31, 2020. 
 
You asked the Plan to pay for home health services. The Plan denied your request. The Plan says a corrected 
claim is needed in order to process. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim did not include a valid rate code. Therefore, we decided that the Plan does not have to pay for 
the home health services provided to the enrollee from January 11, 2020 to January 31, 2020.