Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care services provided from December 24, 2019 to December 31, 2019.
You asked the Plan to waive the copayment for the wound care services. You say that these were regular visits and nothing was mentioned about an additional procedure. You say you feel the $184.22 charge should be deleted. 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 a $250 copayment for each in-network outpatient hospital visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the wound care services.
You have been asked to pay a $184.22 copayment for the wound care services. The wound care services fall within the "Outpatient surgery, including services provided at hospital 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 the wound care services provided from December 24, 2019 to December 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology gene profile provided on November 27, 2019
by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 oncology gene profile provided on November
27, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapy services provided on February 5, 2020 to
March 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient therapy services. You say that you would like this claim reprocessed
and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
The Plan says that an in-network provider did not refer these 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 outpatient therapy services provided on February
5, 2020 to March 5, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) (L0150) provided on November 17, 2019 by a non-participating provider.
You asked the Plan to waive the deductible for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) (L0150) provided on November 17, 2019 by a non-participating provider. At the time of services rendered you had not met your $750 deductible; therefore, you have been asked to pay $100.32 for the services to apply to your deductible. 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 deductible for cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) (L0150) provided on November 17, 2019 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on
February 23, 2020.
You asked the Plan to waive the copayment for urgently needed services. You say that you disagree with the
charges because you were not aware that you were receiving urgent care services. 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 urgently needed services provided at an urgent care center.
You have been asked to pay a $50 copayment for urgently needed services. Urgently needed services fall
within the urgently needed 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
urgently needed services provided on February 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network services at the in-network benefit level.
You asked the Plan to pre-approve out-of-network services at the in-network benefit level. The Plan denied
your request. The Plan says the services are covered under your out-of-network benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that if you need medical
care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you
can get this care from an out-of-network provider.
You are required to pay the out-of-network cost sharing for out-of-network services unless the services are not
available in-network. The requested services are available from an in-network provider. 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 pre-approve out-of-network services at the in-network benefit level.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August
14, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the documentation does not support that services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the
documentation does not support any evidence of an established relationship between the enrollee and the
ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing
have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307
and G0483 provided on August 14, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for polysomnography testing (sleep study) provided from
February 12, 2020 to February 13, 2020.
You asked the Plan to pay for sleep study. You say that this claim is not hospice related. The Plan denied your
request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in a
hospice program on this date of service and therefore the Plan is not responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for polysomnography testing (sleep study) provided from
February 12, 2020 to February 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on January 27, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service is included in the Part A DRG payment to the facility.
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. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on January 27,
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (G0249) provided on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is only covered
once every 25 days.
The Plan must follow Medicare rules. Medicare rules say that code G0249 is covered once every 25 days.
We looked at the file and Medicare rules. The requested show that cod G0249 was paid by the plan on
December 16, 2019. The services in question were provided less than 25 days after that date. 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 (G0249) provided on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on February 18, 2020 by an in-network provider. You asked the Plan to waive the deductible for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on February 18, 2020 by an in-network provider. At the time of services rendered you had not met your $290 deductible; therefore, you have been asked to pay $109.96 for the services to apply to your deductible. 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 deductible for oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) provided on February 18, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve out-of-network outpatient visits. You say that you would like
reconsideration because you liked the care you received from this provider while in the hospital. The Plan
denied your request. The Plan says medically necessary services are available in-network and there are no
extenuating circumstances making it medically necessary to obtain the services out-of-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 items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 16,
2020 through January 21, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have a
copayment since your fall was an accident. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file shows that you were admitted on January 16, 2020 and discharged on January 20, 2020. You
were asked to pay a $390 copayment per day from January 16, 2020 through January 20, 2020, days 1-5 of
your inpatient hospital care. You were discharged on January 21, 2020 and there was no copayment charge for
the day of discharge. Per your contract there is a $390 copayment per day required for days 1-5. 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 inpatient hospital care from January 16, 2020 through January 21,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a coinsurance waiver for Part B drugs.
You asked the Plan to pre-approve the cost share waiver. You say that you are on a limited income. The Plan
denied your request. The Plan says the cost share cannot be waived.
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 are responsible to pay a 20% coinsurance for the drugs. The drugs fall 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 pre-approve a coinsurance waiver for Part B
drugs.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December
26, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you should not be
responsible for the copayment because the urgent care visit was not necessary. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $50 copayment for each urgent care visit.
The enrollee has been asked to pay a $50 copayment for the urgent care visit. The urgent care visit falls within
the "Urgently needed services" benefit category. The record shows that services were received during your
urgent care visit.
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 copayment for the urgent care visit provided on December 26,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown for tooth #19.
You asked the Plan to pre-approve the crown for tooth #19. You say that full coverage is recommended for the
crown to restore form and masticatory function of the tooth. The Plan denied your request. The Plan says the
service is not medically necessary.
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. The Plan covers the crown for
tooth #19 when the services are medically necessary and reasonable.
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 crown for tooth #19. Our reviewer
says that the criteria for coverage has not been met. Our physician reviewer found that tooth #19 has an
existing occlusal restoration. Our physician reviewer also found that since there is no clear need for multi
surface restorations, the requested crown is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown for tooth #19 have not been met. Therefore, we decided that the Plan
does not have to pre-approve the crown for tooth #19.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy with an out-of-network provider.
You asked the Plan to pre-approve the services. 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 radiation
therapy with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chronic care management visit provided
on March 20, 2020.
You asked the Plan to waive the copayment for the chronic care management visit. You say that you were not
seen by the doctor on this date of service. 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 a $5
copayment for each Medicare-covered primary care doctor visit.
You have been asked to pay a $5 copayment for the chronic care management visit. The chronic care
management visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The medical record shows a 20-minute phone call for a care plan follow-up.
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 chronic care management visit provided on March 20,
2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on December 6, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for an ER visit. An ER 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 ER visit provided on
December 6, 2019.