Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on March 4, 2020. 
 
You asked the Plan to pay for a PCD. You say that the durable medical equipment is medically necessary. The 
Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan follows Medicare rules. The rules say that the facility or hospital must furnish all necessary covered 
services to the beneficiary either directly or under arrangements made between the facility hospital and outside 
providers. Applicable payments are payment in full for all facility or hospital services, as defined in 42 CFR 
409.10. CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a 
beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either 
directly or under arrangements. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Medicare rules say that CMS does not pay any provider or supplier 
other than the facility or hospital for services furnished to the beneficiary while an inpatient. The facility or 
hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made between the facility and hospital and outside providers. The enrollee used the equipment in the facility 
during and/or after surgery. Payment for this service would have been included under the facility claim. 
Payment for this service is the responsibility of the facility or hospital that provided the surgery Therefore, we 
decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit (99215) provided on October 15, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $45 copayment for each specialist office visit for Medicare-covered services. You have been asked to pay a $45 copayment for a specialist office visit provided. 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 specialist office visit (99215) provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on March 5, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on March 5, 2019 
by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for SNF care from January 29, 2020 through 
February 23, 2020. 
 
You asked the Plan to waive the copayment for SNF 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).  
 
Records show that you were admitted for SNF care on January 29, 2020 and were discharged on February 23, 
2020. There were no copay charges for the first 20 days (January 29, 2020 through February 17, 2020). You 
were asked to pay a $172 copayment per day for SNF services provided on February 18, 2020, your 21st day of 
SNF care through February 22, 2020. You were discharged on February 23, 2020 and there was no copayment 
charge for the day of discharge. Your EOC states, "enrollees must pay a $0 copayment per day for days 1 to 20 
for Medicare-covered SNF care and a $172 copayment per day for days 21 to 100." 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 SNF care from January 29, 2020 through February 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (J0280) provided on December 2, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is a more 
appropriate code for these services. 
 
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 J0280 is "Injection, aminophyllin, up to 250 mg". 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use 
of code J0280 is not supported by the records provided. Our physician reviewer found that the procedure report 
did not include show an injection of aminophyllin. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (J0280) provided on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the 
enrollee from March 17, 2020 through March 22, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not given a 
choice to have the enrollee stay at a provider since they do not have an intensive care unit, so the enrollee 
should not have an additional copayment. The Plan denied your request. The Plan says the claim was processed 
accordingly with the member's 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 March 17, 2020 and discharged on March 22, 2020. You 
were asked to pay a $250 copayment per day from March 17, 2020 through March 21, 2020, days 1-5 of your 
inpatient hospital care. You were discharged on March 22, 2020 and there was no copayment charge for the 
day of discharge. Per your contract there is a $250 copayment per day required for days 1-7. 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 copayment for inpatient hospital care provided to the enrollee from March 17, 2020 
through March 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided from March 26, 2019 through 
November 19, 2019. 
 
You asked the Plan to pay for incontinence supplies. You say that the incontinence supplies are medically 
necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health 
Plan. 
 
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 pay for incontinence supplies provided from 
March 26, 2019 through November 19, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health services provided to the enrollee on March 16, 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 states this type of service requires referral.  
 
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 out of network mental health services provided to the enrollee on March 16, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided March 26, 2020.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-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 psychotherapy services (90832) provided March 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. There is no 
documentation that you require the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for Hyaluronan injections (J7323) provided 
April 14, 2020 to May 1, 2020. 
 
You asked the Plan to waive the copayment for the Hyaluronan injections. You say that the copayment should 
only be $5.00. The Plan denied your request. The Plan says the correct copayment was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs and a $5.00 copayment for office visits.  
 
You have been asked to pay a 20% coinsurance for Part B drugs (Hyaluronan) and a $5.00 copayment for each 
office visit. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment for Hyaluronan injections (J7323) provided 
April 14, 2020 to May 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from August 
27, 2019 through September 1, 2019. 
 
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied 
your request. The Plan says per Medicare guidelines, the member's services should be billed under Original 
Medicare. 
 
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 August 17, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient hospital 
care provided to the enrollee from August 27, 2019 through September 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a 
participating provider on April 17, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that you were told that 
you would not have a copayment for these services. 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 $45 
copayment for physician/practitioner services/in-network/specialist.  
 
You have been asked to pay a $45 copayment for specialist telehealth services. Telehealth services are still 
subject to copayments; therefore, the correct copayment has been applied. A specialist telehealth services fall 
within the physician/practitioner services/in-network/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 specialist telehealth services provided by a participating provider on April 17, 
2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mammogram (77063, 77067) provided on February 19, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the mammogram. You say that the mammogram should be covered. The Plan 
denied your request. The Plan says services provided out-of-network are only covered when emergent or pre-
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 mammogram (77063, 77067) provided on February 19, 2020 by an out of 
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the duplex scan (93925) provided on August 23, 2019. 
 
You asked the Plan to pay for the duplex scan. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the service was not pre-authorized or emergent. 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 duplex scan (93925) provided on August 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided 
April 8, 2020. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should 
be waived because the health plan stated they would waive copayments for any COVID-19 related services or 
treatments. The Plan denied your request. The Plan says the enrollee was not diagnosed with COVID-19 so the 
copayment cannot be waived. 
 
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. The plan's website notes that the plan is waiving cost sharing for COVID-19 testing and 
treatment of COVID-19. The record does not show that you were tested or treated for COVID-19. Therefore, 
we decided that the Plan does not have to waive the copayment for an emergency room visit (99283) provided 
April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 4, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 4, 2019.
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 September 25, 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 September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation and vertical bitewing x-rays provided on February 27, 2020.
You asked the Plan to pay for the prophylaxis, comprehensive oral evaluation and vertical bitewing x-rays. You say that you needed the services before a scheduled hip replacement. You say that it was a challenge to find a dentist to see you on short notice. The Plan denied your request. The Plan says out-of-network dental 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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis, comprehensive oral evaluation and vertical bitewing x-rays provided on February 27, 2020.