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

 
We decided that the Plan does not have to pay for the laboratory services provided on October 19, 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 had network providers 
available who could have provided 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 October 19, 
2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound of the breast 
(76641) provided on January 30, 2020. 
 
You asked the Plan to waive the copayment for the diagnostic ultrasound. You say that you have never been 
charged $100 for this service before. The Plan denied your request. The Plan says that in 2020, outpatient 
diagnostic ultrasounds have a $100 copayment. 
 
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 other outpatient diagnostic tests, such as an ultrasound.  
 
You have been asked to pay a $100 copayment for the diagnostic ultrasound. A diagnostic ultrasound falls 
within the other 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 
for a diagnostic ultrasound of the breast (76641) provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete lower overdenture (D5865) provided on June 3, 
2020. 
 
You asked the Plan to pay for the dental item. You say that you are allowed $5,000 a year for dental work. You 
say that you were advised that your insurance would pay for anything pertaining to your mouth and dentures. 
You also say that if the implants are covered then the denture that snaps over them should be covered too.  The 
Plan denied your request. The Plan says the overdenture is excluded from coverage. 
 
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 
complete lower overdenture (D5865) provided on June 3, 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 provider on June 1, 2020, to June 18, 2020. 
 
You asked the Plan to waive the copayment for physical therapy. You say that you thought these copayments 
were waived due to Covid-19. The Plan denied your request. The Plan says the correct copayments have been 
applied. The Plan says that physical therapy copayments are not waived due to Covid-19. 
 
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/physical therapy.  
 
You have been asked to pay a $40 copayment for each physical therapy. The total amount you are being asked 
to pay is $240 ($40 x 6 visits = $240). Physical therapy falls within the outpatient rehabilitation 
services/physical therapy 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 provider on June 1, 2020, to June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 4, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on February 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on July 17, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the psychotherapy services. You say that the provider is in network. The Plan 
denied your request. The Plan says prior authorization was required but not requested. 
 
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 had network providers 
available who could have provided 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 the psychotherapy services provided on July 17, 2020 by an out of 
network provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring 
provided on September 15, 2020. 
 
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring (G0453). You say that the 
Plan should pay this claim. The Plan denied your request. The Plan says this codes needs to have a primary 
acceptable CPT code. 
 
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, we have confirmed that code 
continuous intraoperative neurophysiology monitoring G0453 has a bundled relationship with code 95955 and 
cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, 
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 
continuous intraoperative neurophysiology monitoring provided on September 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided July 2, 2020, to July 18, 2020.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that you would like this copayment reprocessed. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 $350 copayment per day for days 1-5 and $0 after day 5 for inpatient hospital care. 

You have been asked to pay a total cost share of $1750 for the inpatient hospital care (5 days x $350 copayment). The services provided fall 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 the inpatient hospital care provided July 2, 2020, to July 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and diagnostic procedures 
provided by a participating provider on May 6, 2020. 
 
You asked the Plan to waive the copayment for an office visit and diagnostic procedures. You say that you 
think you are being incorrectly charged. 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 $35 
copayment for outpatient diagnostic tests/diagnostic procedure and physician/practitioner services/specialty 
physician office.  
 
You have been asked to pay a $35 copayment for an office visit and diagnostic procedures. The total amount 
you are being asked to pay is $99.66 ($35 + $35 + $29.66 = $99.66). An office visit falls within the 
physician/practitioner services/specialty physician office benefit category and diagnostic procedures falls 
within the outpatient diagnostic tests/diagnostic procedure 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 office visit and diagnostic procedures provided by a participating provider on 
May 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
September 15, 2020. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance picked you 
up but they did not deliver you. 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 ambulance services provided on September 15, 2020. You were 
asked to pay a $260 copayment for the ambulance services. Your 2020 EOC states that enrollees must pay a 
$260 copayment for Medicare-covered ambulance transport (one-way). 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 September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eye refraction provided on September 10, 2020. 
 
You asked the Plan to pay for the eye refraction. You say that this was a routine visit. The Plan denied your 
request. The Plan says this was not a routine visit and an eye refraction is not covered when it is NOT a routine 
visit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case.  
 
 
 
 
 
 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eye refraction have not been met. It was verified that eye refractions are only covered during a 
routine exam performed by a Supplemental Routine Vision Care Provider. Review of the medical records 
received from your visit on September 10, 2020, verify that your appointment was not a routine exam. Your 
2020 EOC states, "enrollees must pay a $35 copay for each visit to a specialist, such as an ophthalmologist or 
optometrist, for Medicare-covered benefits. Covered services include: Outpatient physician services for the 
diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular 
degeneration. Original Medicare doesn?t cover routine eye exams (eye refractions) for eyeglasses/contacts. 
Routine vision care: Covered services include: Eye refractions during a routine exam performed by an 
Supplemental Routine Vision Care Provider. Therefore, we decided that the Plan does not have to pay for the 
eye refraction provided on September 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transportation: wheelchair van provided to 
the enrollee on September 19, 2020. 
 
You asked the Plan to pay for the services. You say that you did not give the nursing home permission to use a 
non-covered transportation vendor to bring the enrollee home. The Plan denied your request. The Plan says 
medical records confirm that the enrollee was transported from the facility for non-emergent, planned 
transportation via wheelchair van. The Plan states the enrollee's EOC and Medicare rules specifically state that 
wheelchair van transportation is not a covered benefit for the enrollee. The Plan must follow Medicare rules. 
The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked 
the Plan to pay for are wheelchair van transport services. The enrollee's 2020 EOC states that wheelchair van, 
stretcher van and ambulette transportation are not covered. Therefore, we decided that the Plan does not have to 
pay for non-emergency transportation: wheelchair van provided to the enrollee on September 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab testing services (84480, 36415) 
provided on January 10, 2020. 
 
You asked the Plan to waive the deductible for lab testing services. You say that you have never paid for lab 
testing before, and the Plan's EOC says there is no cost to you for lab testing. The Plan denied your request. 
The Plan says a deductible applies to laboratory services, and as of January 10, 2020, the deductible had not 
been met. 
 
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 $250 deductible for laboratory testing. The EOC also states that you 
pay $0 for lab testing after the deductible has been met. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category laboratory 
testing. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 
deductible for laboratory testing. This cost sharing is a contractual obligation that had not been met at the time 
lab testing services was received on January 10, 2020. Therefore, we decided that the Plan does not have to 
waive the deductible for the lab testing services (84480, 36415) provided on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the allergy patch test (95044) provided on 
February 24, 2020. 
 
You asked the Plan to waive the copayment for the allergy patch test. You say that you cannot find where the 
EOC specifies that an allergy patch test is subject to a $50 copayment. The Plan denied your request. The Plan 
says the $50 copay was applied 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 $50 
copayment for physician/practitioner services provided by a specialist.  
 
You have been asked to pay a $50 copayment for the allergy patch test. An allergy patch test falls within the 
physician/practitioner services provided by a specialist 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 allergy patch test (95044) provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 1, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained or on file. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided 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 physician services provided on September 1, 2020 
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT Code L0651) provided to the 
enrollee on September 22, 2020. 
 
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the orthosis have not been met. The date of service is different 
from the delivery date and shipping date. Per 49 CFR Section 1503.409 - Service of documents, the billed date 
of service should be the date of delivery, the date of mailing or the date shown on the postmark. Therefore, we 
decided that the Plan does not have to pay for lumbar-sacral orthosis (CPT Code L0651) provided to the 
enrollee on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 5, 2020 to 
January 13, 2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were medically 
necessary. The Plan denied your request. The Plan says that the inpatient stay was not medically necessary and 
a lower level of care would have been more appropriate. 
 
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 review indicates that the enrollee was a then, 86-year-old female with a history of diabetes, 
hypertension, renal cyst, aortic insufficiency, SVT, bifascular block, hypothyroidism and chronic kidney 
disease who presented to the emergency room on January 5, 2020, with shortness of breath and a productive 
cough. The member was diagnosed with pneumonia. She was started on antibiotics and steroids. The review 
has determined that the record show 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 January 5, 2020 to January 13, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 26, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says while you are a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 26, 2020.