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

 
We decided that the Plan does not have to waive the copayment for cardiac device monitoring (93295, 93296) 
provided June 8, 2020. 
 
You asked the Plan to waive the copayment for the cardiac device monitoring. You say that the copayment 
should be waived. The Plan denied your request. The Plan says the correct copayment 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 $50 
copayment for Diagnostic Testing.  
 
You have been asked to pay a $50 copayment for the cardiac device monitoring. The cardiac device monitoring 
falls within the Diagnostic Testing 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 
cardiac device monitoring (93295, 93296) provided June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for cardiac device monitoring (93298, G2066) 
provided March 8, 2020. 
 
You asked the Plan to waive the copayment for the cardiac device monitoring. You say that the copayment 
should be waived. 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 $50 
copayment for Diagnostic Testing.  
 
You have been asked to pay a $50 copayment for the cardiac device monitoring. The cardiac device monitoring 
falls within the Diagnostic Testing 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 
cardiac device monitoring (93298, G2066) provided March 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for aquatic therapy provided. 
 
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved, so 10 visits were 
provided. You say that the claims should be processed for payment. The Plan denied your request. The Plan 
says the techniques used could have been applied using land based physical therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 
 
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 aquatic therapy. Our reviewer says that 
skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found there was no documentation in the records that land based physical 
therapy would have been inappropriate for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not 
have to pay for aquatic therapy provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric reclining chair. 
 
You asked the Plan to pre-approve an electric reclining chair. You say that you need a recliner because of your 
medical condition. The Plan denied your request. The Plan says an electric reclining chair is not covered by 
Medicare.  
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. The upholstered portion of a seat lift chair is not covered by Medicare. 
 
We looked at the file and Medicare rules. The record does not show that you are unable to stand up from a 
regular armchair or that the seat lift mechanism is part of your practitioner's course of treatment for your 
condition. Based on this information, we decided that Medicare rules for coverage of an electric reclining chair 
have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric reclining chair.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you had on December 30, 
2019. 
 
You asked the Plan to waive the copayment for the lab services. You say that you had this blood drawn at your 
PCP's office and you had no control over where the doctor sent the specimen.  You said that because the lab 
services was done at your PCP's office, there should be no copayment. The Plan denied your request. The Plan 
says you were charged this copayment 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 $45 
copayment for lab services at an outpatient hospital facility.  
 
You have been asked to pay a $45 copayment for the lab services. Records show that the actual blood draw 
(code 36415) and the processing of the bloodwork both took place at an outpatient hospital facility. Your PCP 
did not bill for the blood draw itself, the hospital did. Because of that, the lab services fall within the lab 
services at an outpatient hospital facility benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for lab services you had on December 30, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 16, 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 codes 80157, 80177, 80201, 80162, 80159 and 80173 are not supported. 
 
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 80157, 80177, 80201, 80162, 80159 and 80173 are not supported in the medical 
record. Specifically, there is no documentation of testing on blood samples. 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 laboratory services rendered on April 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Abatacept infusions you received from January 30, 2020 to May 1, 2020.You asked the Plan to waive the coinsurance forthe Abatacept infusions. You say that you were told that if you had these services at the clinic it would be at no cost to you.The Plan denied your request. The Plan says you were charged this coinsurance correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the Abatacept infusions. The Abatacept infusions fall within the Medicare Part B 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 forthe Abatacept infusions you received from January 30, 2020 to May 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services (01830 and 64415) provided. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the documentation submitted did not include 
medical records for the billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the anesthesia services have not been met. Specifically, there is insufficient information to 
determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not 
have to pay for anesthesia services (01830 and 64415) provided.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis you had on May 29, 2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you don't think this test was 
necessary and that you cannot afford this copayment. The Plan denied your request. The Plan says you were 
charged this copayment 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 $180 
copayment for advanced imaging services.  
 
You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the advanced imaging 
services benefit category. This copayment applies regardless of the reason for the test. 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 computed tomography (CT) scan of the abdomen and pelvis you 
had on May 29, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on February 3, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that it is not 
appropriate to bill Medicare for services that are not covered. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
The lab services were provided by a contract provider. The file does not show that the Plan provided notice that 
the lab services would not be covered. Under Medicare rules, this means the lab services is considered 
approved by the Plan. Therefore, we decided that the Plan has to pay for the lab services provided on February 
3, 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 pre-approve an additional lithium battery for an oxygen 
concentrator. 
 
You asked the Plan to pre-approve additional battery. You say that you are limited to what you can do and just 
want to be able to live more comfortably. The Plan denied your request. The Plan says the denial of 
authorization for this item is correct, because you already have a battery for your oxygen concentrator and your 
current equipment should be assessed due to your claims of low charge. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you already have a battery for your oxygen concentrator. An additional battery would serve 
the same purpose as your current battery. Therefore, we decided that the Plan does not have to pre-approve an 
additional lithium battery for an oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physician services provided to the enrollee out of 
network on February 6, 2020.  
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for 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 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 physician services provided to the enrollee out of network on 
February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments and remove the charge for the outpatient 
services provided on July 2, 2020 and July 9, 2020. 
 
You asked the Plan to waive the copayments and remove the charge for the outpatient services. You say that 
the Plan should cover these services. The Plan denied your request. The Plan says you were charged the 
outpatient service copayments correctly and astigmatism correcting function of intraocular lens is not covered 
by Medicare. 
 
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 Outpatient Hospital Service.  
 
You have been asked to pay a $250 copayment for each of the outpatient services. The outpatient services fall 
within the Outpatient Hospital Service 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. The astigmatism correcting function of intraocular lens (V2787) is not covered 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to waive the copayments or remove 
the charge for the outpatient services provided on July 2, 2020 and July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services 
you received from July 1, 2020, to July 8, 2020. 
 
You asked the Plan to waive the copayment for the SNF services. You say that you could have been released 
from the facility before the copayment kicked in. The Plan denied your request. The Plan says you were 
charged this copayment 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 $0 
copayment per day for days 1-20, and a $125 copayment per day for days 21-40 for skilled nursing facility 
services.  
 
Records show that you were admitted to the SNF on June 15, 2020, and you remained in the SNF until July 8, 
2020.  This is a total of 23 days.  This appeal addresses only the dates of service in July.  Based on your 
contract, you pay $0 per day for the first 20 days of your stay.  For the remaining 3 days of your stay, you were 
charged a $125 copayment per day, for a total of $375. 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. This cost sharing applies regardless of the reason for the length of the stay. 
Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) 
services you received from July 1, 2020, to July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that your provider says this service is an 
important part of your treatment, and you would like it approved. The Plan denied your request. The Plan says 
this service is not covered under your benefit plan. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided from June 15, 
2020, to June 29, 2020. 
 
You asked the Plan to pay for out of network physician services provided to the enrollee. You say that the 
enrollee was dismissed from the hospital to an out of network nursing home beyond his control. You were 
aware that you needed to get his insurance in order but were unable to do so prior to July 1, 2020. The Plan 
denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician 
services provided from June 15, 2020, to June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you need this for when you go out of 
your house. The Plan denied your request. The Plan says this is not necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scale (E1639). 
 
You asked the Plan to pre-approve a scale. You say that you need this to weigh yourself every day. The Plan 
denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a scale (E1639).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided. 
 
You asked the Plan to pay for these services. You say that the Plan should not cover these services because you 
did not know the provider was not in network. The Plan denied your request. The Plan says you did not have 
prior authorization for 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 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 out of network physician services provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram, breast 
ultrasound, and breast tomosynthesis you had on July 14, 2020. 
 
You asked the Plan to waive the deductible for the diagnostic mammogram, breast ultrasound, and breast 
tomosynthesis. You say that you are nervous because you cannot pay this bill. The Plan denied your request. 
The Plan says the charges for these services were assessed against your annual deductible.  You had not yet 
met your deductible at the time of these services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible that applies to diagnostic imaging services.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that 
applies to diagnostic imaging services such as the diagnostic mammogram, breast ultrasound, and breast 
tomosynthesis that you received. This cost sharing is a contractual obligation that had not been met at the time 
the services were received on July 14, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for the diagnostic mammogram, breast ultrasound, and breast tomosynthesis you had on July 14, 
2020.