Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the specialist office visit. We decided that the Plan
does not have to waive the copayment for the specialist office visit.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up to
your surgery and the visit should be 100% covered. The Plan says that you have been charged the correct cost
sharing amount.
We decided that the Plan has to reduce the copayment for the specialist office visit.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles, and coinsurance). The records show that the Plan applied the 2019 specialist
office copayment to the visit on January 6, 2020.
The Plan says that you must pay a $30 for the specialist office visit. Based on the plan contract, however, you
cannot be asked to pay more than a $20 copayment for the specialist office visit. Therefore, we decided that the
Plan has to reduce the copayment from a $30 copayment for the specialist office visit to a $20 copayment for
the specialist office visit.
We also decided that the Plan does not have to waive the copayment for the specialist office visit.
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 the specialist office visit. Please note, there is no provision in the contract which indicates a
copayment would be waived if performed as a follow-up to a surgical procedure.
Therefore, we decided that the Plan does not have to waive the copayment for the specialist office visit.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 16,
2020 through March 17, 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 review has determined that the record did not show that at the time of inpatient
admission the admitting physician reasonably expected that the patient's necessary hospital care (including
earlier emergency department (ED) and/or observation care) would span two midnights.
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 March 16, 2020 through March
17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the plan does not have to waive the coinsurance for oxygen concentrator provided by
O2, an out-of-network provider, from October 1, 2019 through November 1, 2019.
You asked the plan to waive the coinsurance for the DME. You say that you are appealing the nonpayment
of the rental charges of the DME, because you would like for the plan to consider covering it as an
extra-contractual benefit, and treat the provider as an in-network provider. The plan denied your
request. The plan says you were reimbursed 50% of the submitted amount based on your 2019 EOC.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information
(such as copayments, deductibles and coinsurance).
The plan is unable to reimburse you for rental of DME item as the plan has previously reimbursed you for the
purchase of the item at the out-of-network benefit level. Additionally, the plan cannot honor your request to
receive in-network DME provider rental payments of on a monthly basis for the rental of this equipment,
because you are not a DME provider. 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 Blue Advantage does not have to waive the
coinsurance for oxygen concentrator provided by O2, an out-of-network provider, from October 1, 2019
through November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from January 20, 2020
through January 23, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights.
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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from January 20, 2020 through January 23, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided by on
November 25, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the
orthoses are medically necessary. The Plan denied your request. The Plan says the orthoses are not medically
necessary.
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 the knee orthosis (L1851) and suspension
sleeve (L2397). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found
the health plan's denial should be upheld. The enrollee is reported to have chronic left knee pain. No detailed
history, recent injury or surgery, associated symptoms or review of systems is noted. The physical examination
consists of findings that can be reported by the enrollee, rather than observed by the examiner. There is no
evidence of diagnostic evaluation (i.e. x-rays) or prescription therapy provision/response (i.e. prescription
meds, injections, PT/OT). Therefore, the documentation does not support the medical necessity or
reasonableness of the provided service.
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 knee orthosis (L1851) and suspension sleeve (L2397) have not been met.
Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided
on November 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation, including consultation, (D9310) provided on
January 13, 2020.
You asked the Plan to pay for the dental service. You say that you would like a list of in network dental
providers as soon as possible. You say that you would like to be able to schedule future dental appointments
and the services be covered in full. The Plan denied your request. The Plan says the consultation, including
evaluation, is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the consultation is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the evaluation,
including consultation, (D9310) provided on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the trigger finger surgery provided on
December 16, 2019.
You asked the Plan to waive the coinsurance for the trigger finger surgery. You say that you were told that all
charges would be taken care of for this surgery and you were never told the provider was not in-network. 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 30%
coinsurance for each out-of-network Medicare-covered surgical service.
You have been asked to pay a total of $3,923.48 for the trigger finger surgery. The trigger finger surgery falls
within "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows the provider is out-of-network. See chart below.
Date of Service Service Allowed Amount Coinsurance Member Liability
December 16, 2019 Trigger finger
surgery
$15,870.96 30% $3,923.48 - This is
less than the
standard amount.
Total $
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 trigger finger surgery provided on December 16, 2019.
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 June
24, 2019 to July 8, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says these services were not billed correctly.
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, this claim
was submitted with an invalid Type of Bill code and is missing the required Q and HIPPS codes. Therefore, we
decided that the Plan does not have to pay for the home health services provided to the enrollee from June 24,
2019 to July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a Group 2 PWC is covered when specific criteria
are met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records support that the
enrollee is able to operate a manually wheelchair with non-powered accessories. There is no recent physician
assessment of his deficits, except one with copied content from the therapist supporting the power chair. The
file also shows that the PWC is being requested for use outside of the home. The PWC is not reasonable or
medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Furthermore, the PWC is being requested for
use outside of the home and Medicare does not cover the item for this purpose. Therefore, we decided that the
Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Practitioner Services
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 on November 8, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
available in-network.
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
on November 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections (J0585).
You asked the Plan to pre-approve Botox injections. You say that this is medically necessary. The Plan denied
your request. The Plan says this drug is not necessary for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
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 Botox injections. Our reviewer says
that the requested injections are not supported for the enrollee in this case. Our physician reviewer found the
medical record does not support the accepted definition of cervical dystonia, which is characterized by
sustained or intermittent abnormal postures and/or movements of the head, neck, or upper body. The medical
record is consistent with a diagnosis of myofascial pain syndrome and cervicogenic headaches, which are not
covered indications for Botulinum toxin injection. In addition, previous Botox injection therapy for treatment
of her migraines was not beneficial. The documentation does not support that the Botox is medically reasonable
or necessary for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does
not have to pre-approve Botox injections (J0585).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing provided on December 11, 2019.
You asked the Plan to pay for the testing services. You say that the test provides a safe and validated strategy to
reduce the number of unnecessary prostate biopsies. The Plan denied your request. The Plan says the service is
not a Medicare benefit.
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. The rules say that the use of the 4Kscore test algorithm is noncovered.
Therefore, we decided that the Plan does not have to pay for the 4Kscore testing provided on
December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat
exchanger.
You asked the Plan to pay for the perfusionist services (99190). You say that this equipment was provided to
the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this
claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers.
This equipment was used during and after a surgical procedure by the facility. Payment for this service would
have been included under the facility claim. Payment to you for this service is the responsibility of the facility
or hospital. Based on this information, we decided that Medicare rules for coverage of the perfusionist services
(99190) have not been met. Therefore, we decided that the Plan does not have to pay for assembly and
operation of pump with oxygenator or heat exchanger.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88112) provided on January 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service
cannot be verified.
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 88112 is "Cytopathology, selective cellular enhancement
technique with interpretation (e.g., liquid based slide preparation method), except cervical or vaginal".
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 the services. Our reviewer says that the use
of CPT code 88112 is not supported by the records provided. Our physician reviewer found that there is no
indication "Cytopathology, selective cellular enhancement technique with interpretation" was completed.
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 pay for the services (CPT 88112) provided on January 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a follow-up visit to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the visit. The Plan denied your request. The Plan says the services are
available in-network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a followup
visit to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 19, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis
provided on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an infusion pump (E0781) provided
January 6 to February 6, 2020.
You asked the Plan to waive the coinsurance for the infusion pump. You say that the coinsurance should be
waived. The Plan denied your request. The Plan says the correct cost-sharing 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 20%
coinsurance for Durable Medical Equipment.
You have been asked to pay a 20% coinsurance for the infusion pump. The infusion pump falls within the
Durable Medical Equipment 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 an infusion
pump (E0781) provided January 6 to February 6, 2020.