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

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
March 28, 2020. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you went for testing 
services and did not expect any charges. The Plan denied your request. The Plan says the copayment you are 
being charged is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for each Medicare-covered emergency room visit.  
 
You have been asked to pay $40.76, which is less than your $90 copayment for emergency room services. 
Emergency room services fall 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 emergency room services provided on March 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on 
May 8, 2020. 
 
You asked the Plan to pay for the re-cement or re-bond of a crown. You say that you gave the provider your 
insurance card, and were given an okay over the phone. The Plan denied your request. The Plan says this 
service is not a covered benefit under your dental 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 pay for the re-
cement or re-bond of a crown (D2920) provided on May 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on December 17, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says this provider is not a network provider with the Plan. The Plan states they determined 
that these services are not urgent or emergent and they were not approved in advance. 
 
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 services provided on December 17, 2019 by an 
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for external mobile cardiovascular telemetry 
provided on February 7, 2020. 
 
You asked the Plan to waive the coinsurance for external mobile cardiovascular telemetry. You say that the 
device did not work so you returned it and you never received a test. 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 15% 
coinsurance for non-radiological diagnostic services. 
 
The medical records show that you received external medical cardiovascular telemetry on February 7, 2020. 
Therefore, you are responsible to pay your share of the cost-sharing charges. The allowed amount is $670 and 
20% of that is $100.50.   
 
You have been asked to pay the total coinsurance amount of $100.50 for external mobile cardiovascular 
telemetry. External mobile cardiovascular telemetry 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 coinsurance for external 
mobile cardiovascular telemetry provided on February 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on November 2, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for podiatry services. You say that you were not aware the provider was out-of-
network at the time of this service. The Plan denied your request. The Plan says prior authorization was not 
obtained. The Plan says these services were not urgent in nature. 
 
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 podiatry services provided on November 2, 2019 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 4kscore testing rendered on March 10, 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. The rules say that 4Kscore testing is not reasonable and necessary and is 
not covered by Medicare. 
 
The test at issue is the 4Kscore test. This test is not covered by Medicare for any indication. Therefore, we 
decided that the Plan does not have to pay for 4kscore testing rendered on March 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on November 5, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating 
physician and was not offered by an in-network laboratory. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because this provider is out-of-network with the Plan, the 
ordering physician is also out-of-network with the Plan, and 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 the medical services provided on November 5, 
2019 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 a specialist visit provided on January 29, 
2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges 
because you were at the hospital overnight. 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 each specialist visit for outpatient hospital services.  
 
The medical records show that you received a specialist visit during an observation stay on January 29, 2020. 
Therefore, you are responsible to pay the $20 copayment.  
 
You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the outpatient 
hospital 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 a specialist visit 
provided on January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960), a wrist-hand orthosis 
(L3916), a knee orthosis with suspension sleeve and knee accessories (L1851, L2397, L2385, L2820, L2830), a 
lumbar-sacral orthosis (L0650), and an ankle-foot orthosis with stabilizer (L1971, L3170) provided to the 
enrollee on April 29, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 a shoulder-hand-wrist orthosis (L3960), a wrist-hand orthosis 
(L3916), a knee orthosis with suspension sleeve and knee accessories (L1851, L2397, L2385, L2820, L2830), a 
lumbar-sacral orthosis (L0650), and an ankle-foot orthosis with stabilizer (L1971, L3170) provided to the 
enrollee on April 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient established patient office visit (99214) 
provided January 8, 2020. 
 
You asked the Plan to pay for the office visit. You say that you cannot find any physician in your area that 
prescribes the medication for your condition. The Plan denied your request. The Plan says the plan cannot pay 
a provider who is not eligible to participate in Medicare. If you go to a provider who is not eligible to 
participate in Medicare, you will be responsible for the full cost of the services you receive. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the outpatient established patient office visit (99214) provided January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on June 25, 2019 through 
July 17, 2019. 
 
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because this 
claim was billed correctly. The Plan denied your request. The Plan says this claim was submitted with an 
inappropriate discharge status code. 
 
The Plan must follow Medicare rules. Medicare rules say that Substance Abuse Facilities are not eligible to 
enroll in Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Specifically, the NPI billed on this claims indicates that 
this provider is a Substance Abuse Facility. Substance Abuse Facilities are not eligible to enroll in Medicare. 
Therefore, we decided that the Plan does not have to pay for the outpatient services provided on June 25, 2019 
through July 17, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy (97110, 97112, 97530) 
from March 9 to April 15, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you were not adequately 
informed of the change in the copayment for the 2020 benefit year. 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 $25 
copayment for physical therapy at a specialist's office or a comprehensive outpatient rehab facility.  
 
You have been asked to pay $475, or a $25 copayment for each of 19 sessions, for physical therapy. Physical 
therapy falls within the "Outpatient rehabilitation 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 physical therapy (97110, 97112, 97530) from March 9 to April 15, 2020.  
 
Your complaint about not being adequately informed of the change in the copayment for the 2020 benefit year 
is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by 
the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network 
(OON) provider on March 6, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the office visit (99214) rendered by the out of network (OON) provider on March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 19, 2020 to May 
21, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The 
Plan denied your request. The Plan says that the enrollee could have been treated in observation. 
 
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 presented to the emergency room on May 19, 2020 with left knee pain rated 10/10 
and swelling. On exam he had an effusion of the left knee. Lab studies revealed an elevated white blood count 
and an elevated erythrocyte sedimentation rate. An x-ray demonstrated arthritic changes, fluid and no fractures. 
He underwent arthrocentesis. He was treated with morphine sulfate and antibiotics and was admitted. He was 
evaluated by Orthopedics. His condition stabilized and improved and he was discharged home with outpatient 
follow-up on May 21, 2020. The review has determined that the record showed that at the time of inpatient 
admission the admitting physician reasonably expected that the patient'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 from May 19, 2020 to May 21, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement service (11042) rendered by the out of 
network (OON) provider on September 5, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the debridement service (11042) rendered by the out of network (OON) provider on  
September 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve and knee accessories 
(L1851, L2397, L2385, L2820, L2830), a lumbar-sacral orthosis (L0650), and an ankle-foot orthosis with 
stabilizer (L1971, L3170) provided to the enrollee on April 29, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not indicate services are necessary for treatment of the 
enrollee's condition. 
 
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 a knee orthosis with suspension sleeve and knee 
accessories (L1851, L2397, L2385, L2820, L2830), a lumbar-sacral orthosis (L0650), and an ankle-foot 
orthosis with stabilizer (L1971, L3170) provided to the enrollee on April 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on April 15, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for laboratory tests. You say that you are appealing with records. The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and 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 the medical services provided on April 15, 2020 
by an out of network (OON) provider.