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

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
February 18, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford the 
copayment. 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 $265 
copayment for each ambulance date of service. You had one ambulance date of service. 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 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services received on April 22, 
2020. 
 
You asked the Plan to waive the copayment for the services. You say that you shouldn't have to pay for this as 
it was your annual physical. The Plan denied your request. The Plan says the copayment was applied correctly 
according to your benefits and the services, as lab services are not included with the annual wellness 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 $15 
copayment for Medicare-covered laboratory services.  
 
You have been asked to pay $2.25 for the services. The services fall within the Medicare-covered laboratory 
services benefit category. Your covered annual exam does not include laboratory 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 laboratory services received on April 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the doctor visits you had on March 4, 
2020, and March 25, 2020. 
 
You asked the Plan to reduce the copayments for the doctor visits. You say that the visit on March 4, 2020, was 
with your primary care doctor, so you should only have a $5 copayment.  You also say that you are questioning 
the $5 copayment charged for the telehealth visit you had on March 25, 2020, with your cardiologist. The Plan 
denied your request. The Plan says you were incorrectly charged a $35 copayment for the visit on March 4, 
2020.  The plan has corrected this, and they are now only charging you a $5 copayment for this service. The 
plan says that it could have charged you a $35 copayment for the telehealth visit you had with a specialist on 
March 25, 2020. However, since it was their billing error, they are not going to charge you this full amount and 
are leaving your copayment responsibility to only $5 for this 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 $5 
copayment for primary care physician services and a $35 copayment for specialist services.  
 
You have been asked to pay a $5 copayment for each of the doctor visits. 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 reduce 
the copayments for the doctor visits you had on March 4, 2020, and March 25, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on May 27, 2020. 
 
You asked the Plan to pay for an electrocardiogram. You say that this was medically necessary. The Plan 
denied your request. The Plan says this is not covered as pre-operative testing. 
 
The Plan must follow Medicare rules. Medicare rules say that electrocardiograms performed pre-operatively 
when there are no indications will be denied as not reasonable and necessary. 
 
We looked at the file and Medicare rules. The records indicate that this test was performed pre-operatively 
without other indications or diagnoses. Based on this information, we decided that Medicare rules for coverage 
of an electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an 
electrocardiogram (93010) provided on May 27, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided March 6, 2020 to March 8, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says that the services rendered are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the enrollee had acute onset of dizziness and altered mental status. The documentation supports 
that it was medically appropriate to require an inpatient stay to further work up and evaluate these symptoms. It 
would be necessary to rule out cerebrovascular accident, especially given his history of prior cerebrovascular 
accident. In addition, telemetry monitoring is required to rule out arrythmyias. Therefore, the documentation 
supports that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's 
necessary hospital care (including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided March 6, 2020 to March 8, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on May 
27, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you had an emergency 
issue with your tooth because it broke, and you were in severe pain. The Plan denied your request. The Plan 
says this service is not a covered benefit. 
 
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 pay for the 
problem focused limited oral evaluation provided on May 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the Botox injection provided on June 1, 
2020. 
 
You asked the Plan to reduce the cost sharing for the Botox injection. You say that you have received three 
prior injections which were at a lower cost. You do not agree with being charged $244.40 when the previous 
injection was only $180.76. The Plan denied your request. The Plan says based on the code billed by the 
provider, the allowed amount for the June injection was higher than the previous injections. As such, the 20% 
coinsurance was applied to this higher amount and resulted in a higher enrollee responsibility. 
 
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.  
 
You have been asked to pay 20% coinsurance for the Botox injection. The Botox injection falls within the 
Medicare Part B prescription drugs benefit category. The allowable amount to which a coinsurance is applied is 
subject to change, either due to a change in the fee or due to a difference in dosage. 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 reduce the cost sharing for the Botox injection provided on June 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 11, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory 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 laboratory services provided on February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing rendered on February 20, 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 the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that genetic testing is covered when specific criteria 
are met. 
 
We looked at the file and Medicare rules. There is no documentation to support that the testing meets the 
Medicare criteria for coverage. 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 genetic testing 
rendered on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation and management service provided 
on May 18, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the telephone evaluation and management service. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 telephone evaluation and management service 
provided on May 18, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered 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 laboratory services provided on April 20, 2020 
by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on August 22, 
2019, by an out of network (OON) provider. 
 
You asked the Plan to pay for OON psychotherapy services. You say that this should be covered. The Plan 
denied your request. The Plan says this was 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 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 psychotherapy services (90834) provided on 
August 22, 2019, 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 an inpatient rehabilitation facility (IRF) 
stay provided from August 16, 2019, to September 4, 2019. 
 
You asked the Plan to waive the copayment for inpatient rehabilitation stay. You say that you believed that this 
was a Skilled Nursing Facility which would be fully covered for the first 20 days. The Plan denied your 
request. The Plan says the copayment amount 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 clearly says that you must pay $289 
copayment per day for days 1 to 6 and $0 copayment for additional days for inpatient rehab stay. This hospital 
stay lasted 19 days, resulting in a copayment obligation of $1,734. 
 
You have been asked to pay $289 copayment per day for days 1 to 6 and $0 copayment for additional days for 
inpatient rehabilitation stay. Inpatient rehabilitation stay falls within the Inpatient Hospital 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 inpatient rehabilitation facility (IRF) stay 
provided from August 16, 2019, to September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 17, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as anurgent or emergency situation, has been documented.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 Plandid not pre-approve the laboratory 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 laboratory services provided on January 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
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 services ordered following the non-covered visit are likewise 
non-covered. Therefore, we decided that the Plan does not have to pay for the genetic testing service.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the continuous glucose monitor supplies provided on February 1, 2020. 
 
You asked the Plan to pay for the continuous glucose monitor supplies. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the enrollee did not meet criteria for 
the items rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that continuous glucose monitors and supplies are 
covered for certain indications.  
 
In addition, the rules say that Medicare health plans must make reasonable and diligent efforts to gather and 
forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. The plan provided the rules for coverage, however, did not specify which rule the enrollee did not 
meet. 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the continuous glucose monitor supplies have been met. Review of the file supports that the 
enrollee has diabetes mellitus, has been using a BGM and performing frequent (four or more times a day) 
testing, is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump, and the enrollee's insulin treatment regimen requires 
frequent adjustment by the beneficiary on the basis of BGM or CGM testing results. Therefore, we decided that 
the Plan has to pay for the continuous glucose monitor supplies provided on February 1, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe echocardiography services provided on December 6, 2019.You asked the Plan to waive the copayment forthe echocardiography services. You say that this was a pre-operative test and you feel you shouldn't have a copayment for this service.The Plan denied your request. The Plan says the claim has been processed correctly per your plan 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 you must pay a $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays.You have been asked to pay a $100 copayment for the echocardiography services. the echocardiography services fall within the outpatient diagnostic tests 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 forthe echocardiography services provided on December 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay formolecular genetic screening testing provided to the enrollee on January 30, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that these services are not authorized because screening testing is not a Medicare benefit for the diagnoses as listed on the claim and is done for screening purposes. Medicare non-coverage applies to both contracted and non-contracted providers, and cannot be overridden by plan directed care. The review has determined that the services at issue in this case are not medically reasonable or necessary.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 testing have not been met.Therefore, we decided that the Plandoes not haveto pay formolecular genetic screening testing provided to the enrollee on January 30, 2020.