Persius/hicric huggingface dataset:
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-of-
network provider from October 8, 2019, to January 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
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 
from October 8, 2019, to January 25, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided to the enrollee from August 16, 2019 
through September 14, 2019. 
 
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay was medically necessary. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the medical records provided there 
was no documentation that the patient required skilled nursing services, i.e., the specialized skill, knowledge 
and judgment of a skilled professional nurse was not required to safely and effectively provide medically 
necessary and reasonable treatment. This patient did not require skilled therapy services, i.e., the specialized 
skill, knowledge and judgment of a qualified therapist was not required to safely and effectively provide 
medically necessary and reasonable treatment. Daily skilled services were not required. This patient did not 
require the services on an inpatient basis, in a skilled nursing facility setting. Services in the long-term care 
facility appear to have been custodial. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided to the enrollee from August 16, 2019 through September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dermatology services provided on March 24, 2020 to March 
26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for dermatology services. You say that this is way more than you were quoted. The 
Plan denied your request. The Plan says there are in-network providers available for these services. The Plan 
says that prior authorization was not obtained. 
 
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 dermatology services provided on March 24, 2020 
to March 26, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bilateral knee orthoses (L1851), lumbar-sacral orthosis 
(L0650), suspension sleeves (L2397) and neuromuscular stimulator, electronic shock unit (E0745) provided on 
February 15, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the durable medical equipment (DME) is medically 
necessary. The Plan denied your request. The Plan says the DME is not medically necessary. 
 
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 bilateral knee orthoses 
(L1851), lumbar-sacral orthosis (L0650), suspension sleeves (L2397) and neuromuscular stimulator, electronic 
shock unit (E0745) provided on February 15, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient mental health care provided on 
March 10, 2020. 
 
You asked the Plan to waive the copayment for outpatient mental health care. You say that you were told that 
you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 
copayment for outpatient mental health care.  
 
You have been asked to pay a $35 copayment for outpatient mental health care. Outpatient mental health care 
falls within the outpatient mental health 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 outpatient mental health care provided on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for an X-ray and a CT scan provided from 
April 14, 2020 to April 23, 2020. 
 
You asked the Plan to waive the copayments for an X-ray and a CT scan. You say that you disagree with the 
charges because the provider was in-network. 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 $20 
copayment for X-rays and a $175 copayment for CT scans provided by any provider other than your primary 
care physician. 
 
You had an X-ray on April 14, 2020. Therefore, you are responsible to pay the $20 copayment.  
 
You received a CT Scan on April 23, 2020. Therefore, you are responsible to pay the $175 copayment.   
 
The total amount you owe is: $195.  
 
You have been asked to pay the total copayment amount of $195 for an X-ray and a CT scan. An X-ray and a 
CT scan fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for an X-ray and a CT scan provided from April 14, 2020 to 
April 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services provided on January 30, 2020 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services rendered were 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 genetic testing services provided on January 
30, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis and does not have to waive 
the coinsurance for a Medicare Part B drug provided on June 4, 2020. 
 
You asked the Plan to waive the copayment for arthrocentesis and to waive the coinsurance for a Medicare Part 
B drug. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims 
were processed correctly and the enrollee is 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copayment for specialist services. The enrollees contract with the Plan also clearly says that 
enrollees must pay 20% coinsurance for Medicare Part B prescription drugs. 
 
The enrollee received arthrocentesis on June 4, 2020. Therefore, the enrollee is responsible to pay the $20 
copayment.  
 
The enrollee received a Medicare Part B drug injection on June 4, 2020. The allowed amount is $82.64 and 
20% of that is $16.53.  
 
The total amount you owe is: $36.53.  
 
The enrollee has been asked to pay the total amount of $36.53 for arthrocentesis and a Medicare Part B drug. 
Arthrocentesis falls within the physician/practitioner services, including doctors office visits benefit category. 
A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. 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 arthrocentesis and does not have to waive the coinsurance for a 
Medicare Part B drug provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis (L1851) and a suspension sleeve addition to 
the lower extremity orthosis (L2397) billed for date of service March 12, 2020. 
 
You asked the Plan to pay for the knee orthosis and suspension sleeve addition. You say that the documentation 
clearly shows medical necessity based on the doctor's review of the patient. The Plan denied your request. The 
Plan says the documentation indicates items in dispute are not necessary for treatment of the enrollee's 
condition. 
 
The Plan follows Medicare rules. Medicare rules say that HCPCS code L1851 is covered when certain criteria 
have been met and when medically necessary. Medicare rules also say that addition codes will be denied as not 
reasonable and necessary if the base orthosis is not 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 pay for the knee orthosis and suspension sleeve 
addition. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the 
documentation does not support that there has been a recent injury to or a surgical procedure on the enrollees 
knees. There is insufficient credible objective documentation of joint laxity. The documentation does not 
support that the orthosis in dispute and the addition to the orthosis, is medically reasonable and necessary for 
the enrollee in this case. 
 
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 and suspension sleeve addition have not been met. Therefore, 
we decided that the Plan does not have to pay for a knee orthosis (L1851) and a suspension sleeve addition to 
the lower extremity orthosis (L2397) billed for date of service March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on April 20, 
2020. 
 
You asked the Plan to waive the copayment for a breast ultrasound. You say that you were not informed that 
you would owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 
copayment for diagnostic procedures and tests provided in an outpatient hospital facility. 
 
You have been asked to pay a $100 copayment for a breast ultrasound. A breast ultrasound falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a breast ultrasound provided on April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on February 18, 2020 to March 18, 2020. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you were told that 
these were covered 100%. You say that if you knew there would be a 20% coinsurance you would have denied 
the equipment. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The 
total allowed amount is $5,409.88. The total amount you are being asked to pay is $1,081.98 ($5,409.88 x 20% 
= $1,081.98). Durable medical equipment falls within the durable medical equipment/in-network 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 durable medical equipment provided a 
participating provideron February 18, 2020 to March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from December 30, 2019 to 
February 24, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says this 
provider is not in-network and there is no authorization on file. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided from December 30, 2019 to 
February 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 23, 
2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 subsequent nursing facility care provided on December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ankle foot orthosis, elbow orthosis, lumbar-sacral 
orthosis, the knee orthosis and suspension sleeve, the shoulder-elbow-wrist-hand orthosis, the wrist hand 
orthosis, and electrical stimulator supplies provided on March 25, 2020. 
 
You asked the Plan to pay for the ankle foot orthosis (L1971), elbow orthosis (L3170), lumbar-sacral orthosis 
(L0650), the knee orthosis (L1851)and suspension sleeve (L2397), the shoulder-elbow-wrist-hand orthosis 
(L3960), the wrist hand orthosis (L3916), and electrical stimulator supplies (A4595). You say that the Plan 
should pay this claim. The Plan denied your request. The Plan says there is no itemized shipping/billing invoice 
to indicate the specific supplies and the delivery dates and date of service do not match. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery which support medical necessity for the supplies provided 
in this case. The Invoice of March 24, 2020 does not have an itemized list indicating the specific supplies. The 
Invoice of April 23, 2020 is beyond the date of service on the claim. The record shows that the Plan made 
several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan 
does not have to pay for the ankle foot orthosis, elbow orthosis, lumbar-sacral orthosis, the knee orthosis and 
suspension sleeve, the shoulder-elbow-wrist-hand orthosis, the wrist hand orthosis, and electrical stimulator 
supplies provided on March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and 
services provided November 7, 2019 to November 21, 2019. 
 
You asked the Plan to pay for IRF care. You say that you are requesting reconsideration for the acute inpatient 
rehab stay. The enrollee was in house 11/07/2019-11/21/2019. She required intensive physical and 
occupational therapies while in your level of care. The Plan denied your request. The Plan says the IRF 
services rendered is not medically necessary. The enrollee could be safely and effectively treated in a less 
intensive setting of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee did not require the intensity of 
services provided at an IRF. Specifically, the enrollee is not shown to have required fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs could have been met at a 
lower level of care (ex. SNF/SAR). 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pay for acute inpatient rehabilitation facility (IRF) admission and services provided November 7, 2019 to 
November 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on September 16, 2018. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until March 30, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the ambulance services provided on September 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3 units of non-sterile gloves billed for date of service January 
6, 2020. 
 
You asked the Plan to pay for the 3 units of non-sterile gloves. You say that the medical records provided 
support the services in dispute. The Plan denied your request. The Plan says the billed items which remain in 
dispute are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that 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. The submitted order and delivery supports only two units of non-
sterile gloves. The 3 units of non-sterile gloves billed are not corroborated by the documentation in the 
beneficiary's medical documentation. Based on this, the Medicare rules for coverage of the 3 units of non-
sterile gloves have not been met. Therefore, we decided that the Plan does not have to pay for 3 units of non-
sterile gloves billed for date of service January 6, 2020.