Persius/hicric huggingface dataset:
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 February 2, 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 February 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided from February 7, 2020 to February 
28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for physical therapy provided from February 7, 2020 
to February 28, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible and coinsurance for medical supplies you 
received on April 27, 2020. 
 
You asked the Plan to waive the deductible and coinsurance for the medical supplies. You say that you were 
charged more than you think you should pay for these supplies. The Plan denied your request. The Plan says 
you were assessed a deductible and coinsurance appropriately for these supplies.  The plan says that at the time 
you received these supplies, you had only met $51.91 of your annual $150 deductible. The total bill for these 
supplies was $1632.30.  You were appropriately charged the remaining $98.09 of your deductible, plus 5% 
coinsurance for the remainder ($1632.30-$98.09= $1534.21 x 5% = $76.71).  The remaining deductible 
($98.09) and the coinsurance for the remainder ($76.71) total $174.81, which is exactly what you are being 
charged. 
 
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 $150 deductible for durable medical equipment.  
 
The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit 
category durable medical equipment. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $150 deductible that must be met before the plan will pay for durable medical 
equipment. After the deductible is met, coinsurance of 5% applies to durable medical equipment. This cost 
sharing is a contractual obligation that had not been met at the time the medical supplies was received on April 
27, 2020. Therefore, we decided that the Plan does not have to waive the deductible and coinsurance for 
medical supplies you received on April 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 25 - 
December 27, 2019. 
 
You asked the Plan to pay for the inpatient hospital services. You say that the claim should be re-reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says the enrollee was clinically stable to 
transfer on December 25, 2019 at 6:46 pm. The Plan says that, upon stabilization, they were not 
notified and was therefore unable to transfer the enrollee. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 inpatient hospital services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the treating physicians 
documented that the patient was not stable for transfer on December 23 and December 24, 2019 due to active 
angina and elevated troponins and undergoing a stent procedure. However, based on the clinical information 
and documentation by the treating physicians, the enrollee was stable for transfer on December 25, 2019 at 
1:08 pm. 
 
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 inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient hospital services provided on December 25 - December 27, 2019.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit (99285) on March 
27 to March 30, 2020. 
 
You asked the Plan to waive the copayment for an emergency room visit. You say that the copayment should 
be waived because you were admitted to the hospital subsequent to your emergency room visit. 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 each Medicare-covered emergency room visit and that this copayment is waived if the enrollee 
is admitted to the hospital within 72 hours for the same condition. The Plan contract also defines formal 
admission to the hospital as part of a hospital inpatient stay. 
 
You have been asked to pay a $50 copayment for the emergency room visit. An emergency room visit falls 
within the "Emergency care" benefit category. The case record reflects that, subsequent to your emergency 
room visit, you stayed in the hospital for outpatient observation, not on an inpatient basis. 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 emergency room visit (99285) on March 27 to March 30, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy provided by a 
participating hospital on January 22, 2020 to March 11, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with these 
copayments. The Plan denied your request. The Plan says the correct copayments have 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 $40 
copayment for outpatient rehabilitation services/in-network/physical therapy/outpatient hospital.  
 
You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked 
to pay is $470.17 ($40 x 11 visits = $440 + $30.17 (1 visit) = $470.17). Physical therapy falls within the 
outpatient rehabilitation services/in-network/physical therapy/outpatient hospital 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 provided by a participating hospital on January 22, 
2020 to March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for intravenous infusion, for therapy, 
prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour (CPT Code 96365) and injection, 
golimumab, 1 mg, for intravenous use (CPT Code J1602) provided on March 12, 2020. 
 
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Your copayment for drugs that are injected or infused while you are getting physician, hospital outpatient, or 
ambulatory surgical center services is 20%. Medicare bases the 20% on the average sales price (ASP) of the 
drug, which is listed on the Center for Medicare & Medicaid Services website (www.cms.gov) in the Medicare 
section titled "Medicare Fee-for-Service Part B Drugs." The files are updated every quarter. The ASP 
(Medicare price) for your March 12, 2020, infusion (drug code J1602) is $20.66 per unit and you received 150 
units. We calculate the copayment as $619.80 based on the Medicare ASP as shown above. Your medical 
group has paid the hospital where you received the drug less, and calculated your copayment as $335.74. You 
may want to pay this amount. The provider could discover this error and ask that it be corrected, which would 
increase your copayment to the correct amount according to the Medicare ASP. 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 intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or 
drug); initial, up to 1 hour (CPT Code 96365) and injection, golimumab, 1 mg, for intravenous use (CPT Code 
J1602) provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided from May 4, 2020 to May 13, 
2020. 
 
You asked the Plan to pay for these services. You say that these services should be covered. The Plan denied 
your request. The Plan says not all of the services billed are covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic 
services provided from May 4, 2020 to May 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to correct the copayment for a primary care provider office visit (99212) on May 
18, 2020. 
 
You asked the Plan to correct the copayment for a primary care provider office visit. You say that the Plan 
erroneously classified your primary care provider as a specialist provider. The Plan denied your request. The 
Plan says that the correct copayment for a specialist office visit was applied. 
 
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 enrollees must pay a $5 copayment for primary care physician services.  
 
The Plan says you must pay a $35 copayment for a primary care provider office visit. Based on the Plan 
contract, however, you cannot be asked to pay more than a $5 copayment for a primary care provider office 
visit. Therefore, we decided that the Plan has to correct the copayment for a primary care provider office visit 
(99212) on May 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesia service provided on April 20, 2020. 
 
You asked the Plan to pay for the anesthesia service (01992). You say that the Plan should pay this claim. The 
Plan denied your request. The Plan says medical records to support medical necessity were requested but not 
received. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. There are no medical records documenting the need for this sedation. 
Based on this information, we decided that Medicare rules for coverage of the anesthesia service have not been 
met. Therefore, we decided that the Plan does not have to pay for the anesthesia service provided on April 20, 
2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for continued SNF services after September 30, 2019. 
 
You asked the Plan to pay for SNF care. You say that the services which the enrollee required and received are 
coverable under the Medicare Act. The Plan denied your request. The Plan says that the enrollee's condition no 
longer required daily skilled services at an inpatient SNF level of care. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before September 30, 2019. The Plan must pay for SNF services until the 100-day SNF care benefit 
is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pay for continued SNF services after September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided 
from January 23, 2020 to January 30, 2020. 
 
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you disagree with 
the charges because you already paid a copayment and did not change rooms. 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 $275 
copayment for day 1-6 for inpatient hospital care.  
 
You had an inpatient rehabilitation stay from January 23, 2020 to January 30, 2020. Therefore, you are 
responsible to pay a $275 for days 1-6 (January 23, 2020 to January 28, 2020). The total amount you owe is 
$275 (copayment) x 6 (inpatient rehabilitation days) = $1,650.  
 
You have been asked to pay the total copayment amount of $1,650 for an inpatient rehabilitation stay. An 
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 stay provided from January 23, 2020 to January 30, 
2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services (S9122) provided March 3, 2020 to 
April 10, 2020. 
 
You asked the Plan to pay for the home health services. You say that you did not know that you needed to ask 
any questions other than the ability of the aids and that the aids were COVID 19 free. COVID-19 was running 
rampant through nursing homes and you needed home healthcare. 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 this PPO plan will generally cover your medical care 
as long as the care you receive is considered medically necessary and you receive your care from a provider 
who is eligible to provide services under Original Medicare As a member of the PPO plan you can receive your 
care from either a network provider or an out-of-network provider. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. The 
provider is not eligible to participate in Medicare. 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 home health services (S9122) 
provided March 3, 2020 to April 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted multianalyte assay with algorithmic analysis 
(81599) rendered by the out of network (OON) provider on February 18, 2020. 
 
You asked the Plan to pay for this service. You say that you say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says this 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 unlisted multianalyte assay with algorithmic analysis (81599) rendered by the out of 
network (OON) provider on February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-share for ophthalmological services: medical 
examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 
or more visits (CPT Code 92004) provided on March 9, 2020. 
 
You asked the Plan to waive the cost-share for the services. You say that you are appealing your cost-share 
responsibility for the services you received. The Plan denied your request. The Plan says the claim was 
processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received ophthalmological services on March 9, 2020. At the time of services 
rendered you had not met your $300 deductible; therefore, you have been asked to pay $89.73 for the services 
to apply to your deductible. You then met your deductible with the services; however, this left a remaining 
allowed amount of $21.11. The Medicare-allowed amount for the ophthalmological services is less than the set 
$30 copayment; therefore, you have been asked to pay the lesser amount of $21.11 for the ophthalmological 
services. Your EOC states, "Your combined in-network and out-of-network medical deductible is $300, and 
enrollees must pay a $30 copayment for each Medicare-covered visit." 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 cost-share for ophthalmological services: 
medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new 
patient, 1 or more visits (CPT Code 92004) provided on March 9, 2020.