Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services from September 24, 2019
through October 22, 2019.
You asked the Plan to waive the copayment for surgical services. You say that you believe the claims were
billed inappropriately or by mistake because the procedures rendered were minor and were not emergencies.
The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 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 surgical services from the outpatient department on September 24,
2019, October 1, 2019, and October 22, 2019. You are asked to pay a $425 copayment per date of service.
Your EOC states, "enrollees must pay a $425 copayment for each surgical or observation room service you get
at an outpatient hospital. We cover medically-necessary services you get in the outpatient department of a
hospital for diagnosis or treatment of an illness or injury. Covered services include, but are not limited to:
Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery,
Laboratory and diagnostic tests billed by the hospital, Mental health care, including care in a partial
hospitalization program, if a doctor certifies that inpatient treatment would be required without it, X-rays and
other radiology services billed by the hospital, Medical supplies such as splints and casts, Certain drugs and
biologicals that you can't give yourself." 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 surgical
services from September 24, 2019 through October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the definitive drug testing panel provided on December 18, 
2019. 
 
You asked the Plan to pay for the drug testing. You say that this is medically necessary testing. The Plan 
denied your request. The Plan says the incorrect POS code was used and the order does not indicate what 
testing is requested. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a 
treating provider. 
 
In this case, the order form does not clearly indicate what drugs are requested for testing. Therefore, we 
decided that the Plan does not have to pay for the definitive drug testing panel provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided from October 24, 2019 through December 24, 2019. You asked the Plan to waive the coinsurance for the DME. You say that you called the provider and told them that you wanted this CPAP machine picked up in October 2019. You state you were told it would be looked into but never heard back and the items were finally picked up in February 2020. 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 rented the CPAP machine and heated humidifier for the months of October 2019, November 2019, and December 2019. On October 24, 2019, you purchased the filter, tubing, chamber, mask, headgear, face mask replacement, and cushion. You are responsible for the 20% coinsurance for items purchased and 20% coinsurance for each the DME items are rented. Therefore, the cost share applied to services rendered on 
October 24, 2019, November 24, 2019, and December 24, 2019 is correct and upheld on appeal. 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 the DME provided from October 24, 2019 through December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an injection provided by a participating 
provider on January 13, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you had the injection done 
at in a physician's office. The Plan denied your request. The Plan says the correct copayment 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 $295 
copayment for hospital outpatient facilities surgical centers/in-network.  
 
You have been asked to pay a $295 copayment for an outpatient surgery. The provider who provided these 
services is associated with an outpatient hospital; therefore, an outpatient hospital fee has been applied 
correctly. An outpatient surgery falls within the hospital outpatient facilities surgical centers/in-network 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 injection provided by a participating 
provider on January 13, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99336) provided on January 6, 2020.
You asked the Plan to pay for the rest home visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent and were not authorized. There were network providers available.
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 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 rest home visit (99336) provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 
22, 2019. 
 
You asked the Plan to pay for the drug testing. 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 codes 80307 and G0483 are not supported in the medical record. Specifically, the 
documentation submitted did not include a valid physician order/lab requisition form or medical records signed 
by the ordering physician to show exactly what tests were to be performed. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing coded 80307 and G0483 provided on July 22, 2019.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit (36415, 83690, 
80053, 96360) on March 16, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived as the plan has stated it will waive Copayments related to COVID-19 testing and treatment. The Plan 
denied your request. The Plan says the copayment cannot be waived as the enrollee has no diagnosis of 
COVID-19 and did not receive testing or treatment for it. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls 
within the Emergency Care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an 
emergency room visit (36415, 83690, 80053, 96360) on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit services rendered on January
22, 2020.
You asked the Plan to waive the deductible for these services. You say that you were told that the provider's
office was in-network. The Plan denied your request. The Plan says the deductible was applied correctly.
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 $500 yearly deductible for your covered medical services.
The item or service you asked the Plan to waive the deductible for falls within the primary care physician's
office services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500
yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not
been met at the time these services were received on January 22, 2020. The Plan confirmed that the provider
was not in-network with the Plan until after these services were rendered. Therefore, we decided that the Plan
does not have to waive the deductible for the office visit services rendered on January 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit and the x-ray 
provided on March 16, 2020. 
 
You asked the Plan to waive the deductible for the specialist office visit and the x-ray. You say that these 
services should be covered under your plan benefits. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing amount. 
 
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 $1,000 deductible that applies towards out-of-network specialist 
office visits and out-of-network x-rays.  
 
The specialist office visit you asked the Plan to waive the deductible for falls within the Physician/ 
Practitioner services, including doctor's office visits' benefit category. The x-ray you asked the Plan to waive 
the deductible for falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit 
category.  
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that 
applies towards out-of-network specialist office visits and out-of-network x-rays. This cost sharing is a 
contractual obligation that had not been met at the time the specialist office visit and the x-ray 
were received on March 16, 2020. Therefore, we decided that the Plan does not have to waive the deductible 
for the specialist office visit and the x-ray provided on March 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 18, 2020 to 
March 20, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you are wondering if the Plan would 
reconsider payment for the self-administered drugs. The Plan denied your request. The Plan says these drugs 
are self-administered drugs, and are not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided from March 18, 2020 to March 20, 2020.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on March 24, 
2020. 
 
You asked the Plan to pay for this service. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says this provider is not in network. 
 
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 out of network physician services provided on 
March 24, 2020.
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 October 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve maxillary partial denture, mandibular partial denture, and one dental extraction. You asked the Plan to pre-approve maxillary partial denture, mandibular partial denture, and one dental extraction. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you have exceeded the benefit limit. 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. Review of the file shows that you previously received dentures on April 8, 2019. Five years has not passed since you last received dentures. The plan only covers up to two dental extractions per calendar year. 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 pre-approve 
maxillary partial denture, mandibular partial denture, and one dental extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies. You asked the Plan to pre-approve incontinence supplies. You say that you have bowel movements on yourself and you really need the requested incontinence supplies. You say that you are out of the necessary supplies and you asked the Plan to reconsider providing coverage. The Plan denied your request. The Plan says this item is not a covered benefit. The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.  While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the core buildup and endodontic therapy provided on 
January 31, 2020, and the crown provided on February 21, 2020 and March 13, 2020. 
 
You asked the Plan to pay more for the core buildup, endodontic therapy and crowns. You say that you were 
informed to pay half of the bill up front and see what else will be covered. You say that you assumed insurance 
was covering the rest of the services. The Plan denied your request. The Plan says your provider does not have 
a contract as a participating provider and is allowed to bill the difference of the allowed amount and billed 
amount. 
 
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 Plan is only obligated to pay 50% 
of the allowed amount for your covered dental services. Therefore, we decided that the Plan does not have to 
pay more for the core buildup and endodontic therapy provided on January 31, 2020, and the crown provided 
on February 21, 2020 and March 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoes purchased on January 22, 2020 from an out-of-network
provider.
You asked the Plan to pay for shoes. You say that you are requesting reimbursement of the item purchased. The
Plan denied your request. The Plan says you do not have out-of-network benefits and foot orthotics are not
covered by Medicare or the Plan unless if the shoes are part of a leg brace and are included in the cost of the
brace, or the shoes are for a person with diabetic foot disease.
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.
Review of the file show that you purchased shoes on January 22, 2020 from an out-of-network provider. 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.
Furthermore, orthopedic shoes are covered if shoes are part of a leg brace and are included in the cost of the
brace, or the shoes are for a person with diabetic foot disease. Therefore, we decided that the Plan does not
have to pay for shoes purchased on January 22, 2020 from an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for bilateral heel ulcers. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 30, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a 
physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 
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 drug testing rendered on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 26, 
2020 through February 11, 2020 provided by an in-network provider. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 shows that you were admitted on January 26, 2020 and discharged on February 11, 2020. 
You were asked to pay a $295 copayment per day from January 26, 2020 through January 29, 2020, days 1-4 of 
your inpatient stay. There were no copayment charges from January 30, 2020, day 5 of your inpatient hospital 
care until your day of discharge February 11, 2020. Per your contract there is a $295 copayment per day 
required for days 1-4. for inpatient hospital care. 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 
inpatient hospital care from January 26, 2020 through February 11, 2020 provided by an in-network provider.