Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to hold you harmless for x-rays (77073, 73564) provided on April 29, 2020. 
 
You asked the Plan to hold you harmless for x-rays. You say that this should be covered. The Plan denied your 
request. The Plan says that this was billed incorrectly. 
 
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. 
 
The x-rays at issue were provided by a contract provider. The file does not show that the Plan provided notice 
that x-rays would not be covered. Under Medicare rules, this means x-rays is considered approved by the Plan. 
Therefore, we decided that the Plan has to hold you harmless for x-rays (77073, 73564) provided on April 29, 
2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the EKG provided on June 15, 2020. 
 
You asked the Plan to waive the copayment for the EKG. You say that the plans share of 80% was not paid. 
The Plan denied your request. The Plan says the copayment 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 $30 
copayment for Medicare-covered non-radiological diagnostic services. Examples include, but are not limited to 
EKG?s, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests.  
 
You have been asked to pay $12.90, which is less than the standard $30 copayment for the EKG. The EKG 
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 copayment for the EKG provided on June 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray Services (Q0092) radiologic examination, spine, cervical 
(72040) transportation of portable x-ray equipment and personnel to home or nursing home (R0070) services provided on 
July 20, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the x-ray services. You say that the services were ordered STAT/ASAP and should be 
considered as emergency services. 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 portable x-ray Services (Q0092) radiologic examination, spine, cervical (72040) transportation of 
portable x-ray equipment and personnel to home or nursing home (R0070) services provided on July 20, 2020 by an out 
of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care received on February 24 to February 29, 2020. 
 
You asked the Plan to pay for SNF care. You say that more physical therapy was needed. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that you received physical therapy (PT), 
speech therapy (ST), and occupational therapy (OT) in the SNF. By the dates in question, you were at a stand 
by assist to contact guard assist level with bed mobility and transfers. You required varying assist with 
activities of daily living (ADLs). You were non-weightbearing to both legs. There were no identifiable skilled 
nursing or skilled therapy service needs. You did not meet severity of illness or intensity of service criteria for 
an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care received on February 24 to February 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve the testing. You say that this is medically necessary to know the extent of 
genetic abnormalities. The Plan denied your request. The Plan says the information sent in does not show that 
the testing would significantly change treatment. 
 
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 the testing. Our reviewer says that the 
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that you meet the criteria for this 
testing. There is no documentation that the testing will change your medical management. 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pre-approve genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 30, 2020 by an out of 
network (OON) provider. 
 
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 services were 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 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 July 30, 2020 by 
an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on July 2, 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 procedure code 19081 is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 19081 is 1. You billed 2 units of this code, exceeding the MUE. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the surgical services rendered on July 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the co payment for the endoscopy and x-rays provided. 
 
You asked the Plan to waive the co payment for the endoscopy and x-rays. You say that you were informed at 
each visit that insurance was paying all the fees. You say that you don't feel responsible for these charges. The 
Plan denied your request. The Plan says the co payments applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
co payment for surgery services at an in-network outpatient hospital and a $95 co payment for basic radiological 
services at an in-network outpatient hospital.  
 
You have been asked to pay a total of $293.67 for the endoscopy and x-rays.  
 
Date of Service Service Allowed Amount Standard Co payment Member Liability , Endoscopy $145.41 $295 $145.41 
June 23, 2020 X-Ray $74.13 $95 $74.13 
June 29, 2020 X-Ray $74.13 $95 $74.13 
TOTAL:    $293.67 
  
 
 
The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities 
and ambulatory surgical centers" benefit category. The x-rays fall 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 copayment for 
the endoscopy and x-rays provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services provided from January 8, 2020, to 
July 29, 2020 by an out of network provider. 
 
You asked the Plan to pay for the chiropractic services. You say that the Plan should pay this claim. The Plan 
denied your request. The Plan says you did not request 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 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 chiropractic services provided from January 8, 2020, to July 29, 2020 by 
an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 11, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that network restrictions do not apply to your 
organization, so this claim should be paid. The Plan denied your request. The Plan says unauthorized, non-plan 
care is not covered. 
 
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 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 June 11, 2020 by an out of 
network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental procedure (41874) performed on October 10, 2019. We also decided that the Plan does not have to waive the copayment for a metabolic panel (80048) and a blood count (85027) received on October 10, 2019.

The enrollee asked the Plan to pay for a dental procedure and to waive the copayment for a metabolic panel and a blood count. The enrollee said that these services were medically necessary. The Plan denied the enrollee's request. The Plan says rules for payment for a dental procedure have not been met. The Plan also says that the correct copayment for a metabolic panel and a blood count was applied.

Regarding the request that the Plan pay for a dental procedure:

Medicare generally does not cover dental services. The Plan follows the same rule.

The services the enrollee asked the Plan to pay for involve the care, treatment, filling, removal or replacement of teeth or the structures directly supporting teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a dental procedure (41874) performed on October 10, 2019.

Regarding the request that the Plan waive the copayment for a metabolic panel and a blood count: 

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for Medicare-covered lab services. 

The enrollee has been asked to pay a $10 copayment for a metabolic panel and a blood count. A metabolic panel and a blood count fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that the enrollee has been asked to pay the correct amount based on the Plan contract. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a metabolic panel (80048) and a blood count (85027) received on October 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a skilled nursing stay provided by an out-
of-network provider on September 6, 2019, to September 27, 2019. 
 
You asked the Plan to waive the coinsurance for a skilled nursing stay. You say that you were given a list of 
providers who took your mother's insurance. You say that you feel as though you were misled. 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a 20% coinsurance for skilled nursing facility/out-of-network.  
 
The enrollee has been asked to pay a 20% coinsurance of the allowed amount for a skilled nursing stay. The 
total allowed amount is $9,639.93. The total amount you are being asked to pay is $1,927.98 ($9,639.93 x 20% 
= $1,927.98). A skilled nursing stay falls within the skilled nursing facility/out-of-network benefit category. 
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This 
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we 
decided that the Plan does not have to waive the coinsurance for a skilled nursing stay provided by an out-of-
network provider on September 6, 2019, to September 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required (D2950) 
and crown - porcelain/ceramic (D2740). 
 
You asked the Plan to pre-approve core buildup and crown. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are not covered benefits. 
 
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. Specifically, the services are not listed as a covered benefit in the 
Plan?s EOC. Therefore, we decided that the Plan does not have to pre-approve core buildup, including any pins 
when required (D2950) and crown - porcelain/ceramic (D2740).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 7, 
2020, to June 10, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you are unhappy with 
the care you received and disagree with the charges. 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 $295 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from June 7, 2020, to June 10, 2020. Therefore, you are responsible to pay a 
$295 copayment for days 1-3 (June 7, 2020, to June 9, 2020). $295 (copayment) x 3 (inpatient days) = $885.  
 
You have been asked to pay the total copayment amount of $885 for an inpatient hospital stay. An inpatient 
hospital 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 hospital stay from June 7, 2020, to June 10, 2020.  
 
Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit 
us to make a decision on this type of complaint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that CMS announced a temporary suspension of 
enforcement of certain clinical coverage criteria that applied to respiratory devices, allowing clinicians 
maximum flexibility to determine clinical need. The Plan denied your request. The Plan says the requested 
service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has COPD and lung cancer, which are not covered diagnoses.  She does not have 
cystic fibrosis, bronchiectasis, or neuromuscular disease. There is inadequate evidence to support the efficacy 
of HFCWO in the treatment of COPD or lung cancer. HFCWO is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on July 28 to August 14, 2020. 
 
You asked the Plan to pay for dental services. You say that you were told these services would be a covered 
benefit. The Plan denied your request. The Plan says rules for payment have not been met. 
 
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 dental 
services received on July 28 to August 14, 2020.  
 
Your complaint about receiving erroneous or misleading information about your benefit 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit injections for the enrollee. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is a lack of clinical information. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 the injections. Our reviewer says that 
the requested injections are not medically reasonable or necessary. Our physician reviewer found there is 
insufficient information (PMHx, Dx, lab results) to show that the requested drug is clinically indicated (MAI), 
medically necessary or reasonable for this enrollee. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Retacrit injections for the enrollee.