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

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a 
participating provider on January 25, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that you went against your 
will. You say that you felt it was more like a police interrogation. The Plan denied your request. The Plan says 
the correct copayment has been 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for an emergency room visit. Since an emergency room visit was 
provided the correct copayment has been applied. An emergency room visit falls within the emergency 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 emergency room visit 
provided by a participating provider on January 25, 2020.  
 
We note your complaint about feeling like it was a police interrogation. Your complaint is a grievance that 
must be answered by the health plan. Medicare does not permit us to make a decision about these types of 
complaints.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chiropractic manipulative treatment (98942) 
performed on October 9, 2019. 
 
You asked the Plan to waive the coinsurance for chiropractic manipulative treatment. You say that you were 
told you would have no copayment for this service. The Plan denied your request. The Plan says that the 
correct coinsurance 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 does not say in clear and accurate terms 
how much you should expect to pay for Medicare-covered chiropractic services.  
 
We looked at your contract with the Plan. We did not see where the contract says under what circumstances 
enrollees must pay 20% coinsurance for Medicare-covered chiropractic services. The Plan contract states there 
is 0% coinsurance or 20% coinsurance for these services but does not specify when the 0% applies and when 
the 20% applies. The Plan contract does not clearly say how much enrollees must pay for Medicare-covered 
chiropractic services. This means that the Plan did not follow Medicare rules for disclosure of cost sharing 
information. Therefore, we decided that the Plan has to waive the coinsurance for chiropractic manipulative 
treatment (98942) performed on October 9, 2019.  
 
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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for chiropractic services provided on October 2, 2019. 
 
You asked the Plan to waive the coinsurance for chiropractic services. You say that you were told that there 
would be no cost sharing. The Plan denied your request. The Plan says that the copayment you are being 
charged is correct. 
 
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 does not say in clear and accurate terms 
how much you should expect to pay for Medicare-covered chiropractic services.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a 20% 
coinsurance for Medicare-covered chiropractic services. The Plan contract does not clearly say how much 
enrollees must pay for Medicare-covered chiropractic services. This means that the Plan did not follow 
Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the 
coinsurance for chiropractic services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 18, 2020 by an out-of-
network provider. 
 
You asked the Plan to pay for the medical services. You say that you do not know the provider was out-of-
network. The Plan denied your request. The Plan says you do not have out-of-network benefits. 
 
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 June 18, 2020 by 
an out-of-network provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency department visit (99285) 
from June 3 to June 6, 2019 or to pay for self-administered drugs received from June 3 to June 6, 2019. 
 
You asked the Plan to waive the copayment for an emergency department visit and to pay for self-administered 
drugs. You say that these products or services were billed with an incorrect code. The Plan denied your request. 
The Plan says the correct copayment was applied. 
 
Regarding the copayment for an emergency department 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 $90 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay a $90 copayment for an emergency department visit. An emergency department 
visit falls within the "Emergency 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 emergency department visit (99285) from June 3 to June 6, 2019. 
 
Regarding payment for self-administered drugs: 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs from 
June 3 to June 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 12, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you may have had Covid-
19 so the copayment should be waived. 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 February 
12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to further pay for the anesthesia services provided on November 1, 
2018. 
 
You asked the Plan to further pay for the services provided. You say that you paid the provider money the plan 
says they owe. The Plan denied your request. The Plan says the claim was processed and paid 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 there is a $0 copay for 
physician and professional services in an outpatient hospital or ambulatory surgical center.  
 
The documentation shows that you have a $0 liability for the service at issue. The file shows that the plan has 
processed and paid for the services provided. We found no exception which would require the plan to pay 
additional amounts for the services provided. If you believe the provider has balance billed you, call customer 
care for the claim to be worked out with the plan and provider. Therefore, we decided that the Plan does not 
have to further pay for the anesthesia services provided on November 1, 2018.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from 
August 20, 2019 to February 13, 2020 billed with code S9328. 
 
You asked the Plan to pay for the HIT services. You say that this per diem charge is for the administrative 
work associated with pain pump management. The Plan denied your request. The Plan says this code is not 
valid for Medicare billing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
CPT code S9328 has a status indicator of "I" on the Physician Fee Schedule, meaning that it is invalid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT 
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion 
therapy (HIT) services provided from August 20, 2019 to February 13, 2020 billed with code S9328.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 15, 2020. 
 
You asked the Plan to pay for the services. You say that your primary care physician (PCP) wanted you to have 
treatment for a condition while you were out-of-area. You state that your PCP subsequently provided referral 
for the treatment out-of-area. The Plan denied your request. The Plan says they need a copy of the itemized bill. 
 
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. The Plan needs a copy of the 
itemized bill for the services you received on January 15, 2020. Therefore, we decided that the Plan does not 
have to pay for the services provided on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 13, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the patient was referred for lab services by 
their doctor. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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. 
 
Neither the provider in this case nor the ordering doctor is a network provider with the Plan. The Plan had 
network providers available who could have provided 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 
March 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an aspiration and/or injection of large joint 
or joint capsule (20610) with Euflexxa injection (J7323) on February 24, March 4, and March 16, 2020. 
 
You asked the Plan to waive the coinsurance for an aspiration and/or injection of large joint with Euflexxa 
injection. You say that you were quoted a different price prior to these services. 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 20% 
coinsurance for Medicare Part B prescription drugs. The Plan contract also clearly says that you must pay a $15 
copayment for each visit to a specialist. 
 
You have been asked to pay three $15 copayments for each visit to a specialist and 20% coinsurance for each 
administration of Euflexxa injection. An aspiration and/or injection of large joint falls under the 
"Physician/Practitioner services, including doctor?s office visits" benefit category. Euflexxa injection 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 an aspiration and/or injection of large joint or joint capsule (20610) with Euflexxa injection 
(J7323) on February 24, March 4, and March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 18, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary and 
should be covered. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. 
 
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 December 18, 
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse your payment for the Inogen One Oxygen Concentrator 
(E1390) provided on January 20, 2020. 
 
You asked the Plan to reimburse your payment for the Inogen One Oxygen Concentrator (E1390). You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
denial of payment for these items is correct, because purchased oxygen equipment is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for 
coverage and purchased oxygen equipment is statutorily non-covered. 
 
We looked at the file and Medicare rules. These items are not reimbursable when purchased. Based on this 
information, we decided that Medicare rules for coverage of the Inogen One Oxygen Concentrator (E1390) 
have not been met. Therefore, we decided that the Plan does not have to reimburse your payment for the Inogen 
One Oxygen Concentrator (E1390) provided on January 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee has complex medical 
services that qualify the enrollee for LTACH services. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for LTACH services for medical complex intensity of services, or severity of illness. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not already available at 
the current facility. Our reviewer found that there are no services that the enrollee requires that are not already 
available and covered at the current facility or a lower level of care. Our physician reviewer also found that a 
transfer to a lower level of care which meets the enrollee's needs may be considered soon. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating 
provider on April 16, 2020. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you are normally made aware of 
the copayments that are owed. You say that you were not aware there would be a copayment. The Plan denied 
your request. The Plan says the correct copayment has been 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 $5 
copayment for outpatient diagnostic tests/in-network/basic radiological services.  
 
You have been asked to pay a $5 copayment for an ultrasound. The correct copayment has been applied to the 
service that was provided. An ultrasound falls within the outpatient diagnostic tests/in-network/basic 
radiological 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 ultrasound 
provided by a participating provider on April 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided March 9, 2020 to March 13, 2020 while in the hospital.

You asked the Plan to pay for the self-administered drugs. You say that the drugs should be covered. The Plan denied your request. The Plan says The Part B medical benefit does not pay for self-administered drugs provided in the hospital outpatient setting.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) provided March 9, 2020 to March 13, 2020 while in the hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and 
management of a new patient (CPT Code 99203) and application of a modality to 1 or more areas; traction, 
mechanical (CPT Code 97012) provided from February 10, 2020 through February 27, 2020. 
 
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is not covered when it is billed by a chiropractor. 
 
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 office or other outpatient visit for the evaluation and management of a new 
patient (CPT Code 99203) and application of a modality to 1 or more areas; traction, mechanical (CPT Code 
97012) provided from February 10, 2020 through February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the 
enrollee from March 1, 2020 to March 30, 2020. 
 
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that there was no 
daily skilled nurse or therapist need. 
 
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 the SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition did not meet 
Medicare criteria for SNF services. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pay for the skilled nursing facility (SNF) services provided to the enrollee from March 1, 2020 to 
March 30, 2020.