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

 
We decided that the Plan does not have to waive the copayment for the non-emergent transportation services 
(A0130) provided on June 13, 2020. 
 
You asked the Plan to waive the copayment for the non-emergent transportation services. You say that you 
should not have to pay the copayment for transportation as you have met your maximum out-of-pocket. 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 $10 
copayment for each non-emergent transportation trip. Your contract also says that transportation services are 
not subject to the maximum out-of-pocket. You had 1 non-emergent transportation trip. The Plan charged you 
$10 for these 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 the non-emergent transportation 
services (A0130) provided on June 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital services provided by a 
participating provider on July 13, 2020. 
 
You asked the Plan to waive the coinsurance for outpatient hospital services. You say that you did not attend or 
authorize these services. 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 outpatient surgery.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for outpatient hospital services. The 
total allowed amount is $114.20. The total amount you are being asked to pay is $22.84 ($114.20 x 20% = 
$22.84). Outpatient hospital services falls within the outpatient surgery 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 outpatient hospital services provided by a participating provider on 
July 13, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on 
January 23, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The Plan contract states outpatient mental health requires a 
referral.  
 
The 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 service 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 outpatient mental health care provided to the enrollee on January 23, 2020.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the emergency room physician services provided on 
May 18, 2019. 
 
You asked the Plan to hold you harmless for the physician services. You say that you received a bill from the 
emergency room physician, and you believe that it should be covered by the Plan. The Plan denied your 
request. The Plan says that the provider did not file a claim until more than one year had passed, and this was 
correctly denied payment. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided with the physician services by a contract provider. The contract provider failed to submit a 
claim to the Plan within the allowed time frame. Contract providers are responsible for following all billing 
rules and an enrollee cannot be held responsible for denied charges by a contract provider in this circumstance. 
Therefore, we decided that the Plan has to hold you harmless for the emergency room physician services 
provided on May 18, 2019.  
 
 
 
 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit and coinsurance for 
an injection provided by a participating provider on June 29, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for a specialist office visit and an injection. You 
say that you were never told that this would be so expensive. The Plan denied your request. The Plan says the 
correct copayment and coinsurance 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 physician/practitioner services/specialist and a 20% coinsurance for Medicare Part B 
prescription drugs.  
 
You have been asked to pay a $40 copayment for a specialist office visit and a 20% coinsurance of the allowed 
amount for an injection. The total allowed amount is $4,536. The 20% coinsurance is $907.20 ($4,536 x 20% = 
$907.20). The total amount you are being asked to pay is $947.20 ($907.20 + $40 = $947.20). A specialist 
office visit falls within the physician/practitioner services/specialist and an injection falls within the Medicare 
Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist 
office visit and coinsurance for an injection provided by a participating provider on June 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF System. 
 
You asked the Plan to pre-approve a CardioMEMS HF System. You say that the requested CardioMEMS HF 
System is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF 
System is not medically necessary. 
 
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 pre-approve a CardioMEMS HF System. Our 
reviewer says that the requested CardioMEMS HF System is not medically necessary. Our physician reviewer 
found the enrollee is with a history of diabetes, hypertension, GERD, polio, chronic kidney disease and NYHA 
class III congestive heart failure with preserved ejection fraction (LVEF 77%) requiring hospital admission. 
 
In this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated 
in only one trial to help reduce hospital readmission compared to standard medical therapy.  Moreover, 
concerns have been raised about potential bias in this trial calling into question the results.  Therefore, the 
efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not 
recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not met 
since the device should still be considered experimental or investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a CardioMEMS HF System.
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 on March 16, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 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 
on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical nutrition therapy (97802) provided on June 3, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for medical nutrition therapy. You say that you are the closest hospital to the 
enrollee. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
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 nutrition therapy (97802) provided on 
June 3, 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 the outpatient surgery services provided 
May 19, 2020 to May 30, 2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you should have a 
$5 copay. No one told you this was an outpatient clinic and someone should have told you of the $400 charge. 
The Plan denied your request. The Plan says the claims processed correctly and the correct cost share has been 
applied per the 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 $300 
copayment for each Medicare covered outpatient hospital facility visit.  
 
You have been asked to pay $372.02 $300 copayment for the outpatient surgery services. The plan has agreed 
to remove the $30 copayment but the outpatient surgery services are correct. The Medicare allowed amount is 
less than the listed copayment of $300, therefore the enrollee assessed the lesser Medicare allowed amount of 
$186.01 for each date of service. The outpatient surgery services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers 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 the outpatient surgery services provided May 19, 2020 to May 30, 
2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network physician services provided on June 15, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says you did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services 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 these services. Therefore, we decided that the Plan 
does not have to pay for out of network physician services provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a tissue exam by pathologist (88305) 
performed on February 6, 2019. 
 
You asked the Plan to waive the coinsurance for a tissue exam by pathologist. You say that this bill is an 
overcharge. 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 40% 
coinsurance for Medicare-covered lab services received from an out-of-network provider.  
 
You have been asked to pay $29.28, or less than 40% of the Plan-allowed amount of $74.57, for a tissue exam 
by pathologist. A tissue exam by pathologist falls within the "Outpatient diagnostic tests and therapeutic 
services and supplies" benefit category. This means that you have been asked to pay less than or equal to 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 a tissue exam by pathologist (88305) performed on February 6, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 29, 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 received are not a covered benefit when 
provided by an out-of-network provider. 
 
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 January 29, 
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital care provided on June 17, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient hospital care. You say that the facility did receive an authorization 
for CPT code 27096. The provider is requesting for the approved authorization to the updated with the correct 
HCPCS code G0260 based on the procedure performed. The Plan denied your request. The Plan says enrollee's 
must receive their medical services from an in-network provider with the exception being urgent or emergent 
services. Non-emergent services with non-contracted providers require prior authorization before services 
being rendered. 
 
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 outpatient hospital care provided on June 17, 
2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9501) provided to 
the enrollee from December 11, 2019 to December 17, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an invalid procedure code for this service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that HCPCS code S9501 is not supported in the medical record. Specifically, this code has a status 
indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for 
Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services 
have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy services 
(HCPCS S9501) provided to the enrollee from December 11, 2019 to December 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an MRI of the shoulder. 
 
You asked the Plan to pre-approve an MRI of the shoulder. You say that the requested MRI of the shoulder is 
medically necessary. The Plan denied your request. The Plan says the requested MRI of the shoulder is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 pre-approve an MRI of the shoulder. Our reviewer 
says that the requested MRI of the shoulder is not medically necessary. Our physician reviewer found the 
enrollee is with right lateral shoulder pain and sensation of a mass. There is no change in symptoms or 
documented concern for malignancy. Repeat MRI is not indicated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the shoulder have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an MRI of the shoulder.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment cannot be 
made for these services. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 15, 2020. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance services 
provided on May 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray services provided on May 18, 2020. 
 
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 74019 is radiologic examination, abdomen; 2 views. 
 
We find that CPT code 74019 is not supported in the medical record. Specifically, the documentation submitted 
did not include documentation of radiologic examination, abdomen; 2 views was performed. Based on this 
information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, 
we decided that the Plan does not have to pay for the x-ray services provided on May 18, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on April 15, 2020. 
 
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 billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 80157, 80177, 80201, 80162, 80159, and 80173 is not supported in the medical record. 
Specifically, Carbamazepine, Levetiracetam, Topiramate, Digoxin, Clozapine, and Haloperidol testing with a 
serum specimen was performed with blood sampling. Blood specimen collection is by venipuncture, however, 
the lab requisition states a urine specimen was collected; therefore, the billed services cannot be verified. It 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80157, 
80177, 80201, 80162, 80159, and 80173 provided on April 15, 2020.