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

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out of network (OON) provider on February 6, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service 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 this service. Therefore, we decided that the Plan does not 
have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) 
provider on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99213) on February 
25, 2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that you should not be charged 
separately for an office visit. 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 $45 
copayment for a specialty physician.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit (99213) on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the rental of a portable oxygen system 
(K0738) and an oxygen concentrator (E1390) from November 2019 to June 2020. 
 
You asked the Plan to waive the coinsurance for the rental of a portable oxygen system and an oxygen 
concentrator. You say that you don't have money to pay this charge. The Plan denied your request. The Plan 
says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay $286.44, the sum of 2 payments of $35.22, or 20% coinsurance of the Plan-
allowed amount for 2019 of $176.07, and 6 payments of $36, or 20% coinsurance of the Plan-allowed amount 
for 2020 of $180.03, for the rental of a portable oxygen system and an oxygen concentrator. The rental of a 
portable oxygen system and an oxygen concentrator falls within the "Durable medical equipment (DME) and 
related 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 coinsurance for the rental of a 
portable oxygen system (K0738) and an oxygen concentrator (E1390) from November 2019 to June 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and drug test provided on April 20, 2020. 
 
You asked the Plan to pay for the office visit and drug test. 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 payable. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are 
furnished by a provider or supplier enrolled in the Medicare program. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit and drug test have not been met. Review of the file shows that the provider was not 
Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does 
not have to pay for the office visit and drug test provided on April 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 31, 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 the claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure 
code 81479. 
 
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest visit provided on February 19, 2020. 
 
You asked the Plan to pay for the domiciliary or rest visit. 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 a domiciliary or rest visit provided on February 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from February 26 
to February 29, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not aware of a 
daily copayment. 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 $325 
copayment for days 1-5 of each Medicare-covered hospital admission/stay.  
 
You have been asked to pay a $975 copayment, or $325 for the first 3 days, 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 February 26 to February 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an adhesive wound closure (G0168) 
performed on May 24, 2019. 
 
You asked the Plan to waive the copayment for an adhesive wound closure. You say that this should be a $5 
copayment at most. 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 $400 for 
Medicare-covered outpatient hospital surgery services.  
 
You have been asked to pay $259.64 for an adhesive wound closure. An adhesive wound closure falls within 
the "Outpatient hospital services" benefit category. This means that you have been asked to pay less than the 
full 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 adhesive wound closure (G0168) performed on May 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on 
January 8, 2020 to February 19, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you feel that the charges 
are too high and were not informed of them ahead of time. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received Medicare Part B drugs from January 8, 2020 to February 19, 2020. Therefore, you are 
responsible to pay $1,865, which is less than the 20% coinsurance amount.  
 
You have been asked to pay the total coinsurance amount of $1,865 for Medicare Part B drugs. Medicare Part 
B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for Medicare Part B drugs provided on January 8, 2020 to February 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on January 31, 2020. 
 
You asked the Plan to pay for foot orthotics. You say that your chiropractor said this would be partially 
covered. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on January 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for delivery fees (A9901) for a prosthesis provided May 2, 2020. 
 
You asked the Plan to pay for the delivery fees. You say that the prosthesis was medically necessary and the 
delivery fees should be covered. The Plan denied your request. The Plan says delivery fees are not eligible for 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services which are not reasonable and 
necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body 
member are not covered.  
 
We looked at the file and Medicare rules. The delivery fees are not considered a medical item or service, and 
therefore are non-covered. Based on this information, we decided that Medicare rules for coverage of the 
delivery fees have not been met. Therefore, we decided that the Plan does not have to pay for delivery fees 
(A9901) for a prosthesis provided May 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 5, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the debridement and office visit was medically 
necessary. The Plan denied your request. The Plan says no prior authorization was obtained for the services 
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 podiatry 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 on February 5, 2020 by an out of 
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services provided on December 19, 2019 by 
an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain 
prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the 
facility or the provider. The Plan says that the since prior authorization was not obtained, payment has correctly 
denied. 
 
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 
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 skilled nursing services provided on December 19, 
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit (99214) on June 2, 
2020. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this visit could have been 
a $0 copayment telehealth visit. 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 $45 
copayment per specialist visit.  
 
You have been asked to pay a $45 copayment for a specialist office visit. A specialist office visit falls within 
the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you 
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a 
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan 
does not have to waive the copayment for a specialist office visit (99214) on June 2, 2020.  
 
Your complaint about the provider requiring an in-office visit rather than a telehealth visit 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (K0553) provided February 18, 
2020. 
 
You asked the Plan to pay for the continuous glucose monitor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says the records did not include a valid proof of delivery. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The provided delivery ticket did not include a tracking or 
order number. The delivery ticket was not itemized. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for a continuous glucose monitor (K0553) provided February 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services coded 92014 provided on 
March 3, 2020. 
 
You asked the Plan to pay for the ophthalmological services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the 
documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 92014 is ophthalmological services: medical examination 
and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established 
patient, 1 or more visits. 
 
We find that CPT code 92014 is not supported in the medical record. Specifically, this service was billed with 
diagnosis codes H25.811 (combined forms of age related cataract, right eye) and H25.812 (combined forms of 
age-related cataract, left eye). There is a more specific code for a bilateral diagnosis. Based on this information, 
we decided that Medicare rules for coverage of the ophthalmological services have not been met. Therefore, we 
decided that the Plan does not have to pay for the ophthalmological services coded 92014 provided on March 3, 
2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for a specialist visit and pulmonary function 
testing provided on September 16, 2019. 
 
You asked the Plan to waive the copayments for a specialist visit and pulmonary function testing. You say that 
you feel that the charges are outrageous especially due to the care you received. 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 $60 
copayment for out-of-network specialist services. Your contract with the Plan also clearly says that you must 
pay a $200 copayment for out-of-network outpatient diagnostic tests. 
 
You received a specialist visit with an out-of-network provider, on September 16, 2019. Therefore, you are 
responsible to pay the $60 copayment.  
 
You received pulmonary function testing with an out-of-network provider, on September 16, 2019. Therefore, 
you are responsible to pay the total allowed amount of $147.97, which is less than the $200 copayment.  
 
The total amount you owe is: $207.97.   
 
You have been asked to pay the total copayment amount of $207.97 for a specialist visit and pulmonary 
function testing. A specialist visit falls within the physician/practitioner services, including doctor?s office 
visits benefit category. Pulmonary function testing 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 copayments for a specialist 
visit and pulmonary function testing provided on September 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nurse practitioner visit you had on April 
7, 2020. 
 
You asked the Plan to waive the copayment for the nurse practitioner visit. You say that you received these 
services from a nurse practitioner and the claim shouldn't have processed under your home health benefits. The 
Plan denied your request. The Plan says it did not process this claim under your home health benefits.  The 
Plan says that you were properly assessed this copayment as a specialist service. 
 
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 services obtained from a specialist , nurse practitioner or physician's assistant, or other non-
physician health care professionals in a specialist's office.  
 
You have been asked to pay a $45 copayment for the nurse practitioner 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 the nurse practitioner visit you had on April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the continuous positive airway (C-PAP) 
supplies you received on March 19, 2020. 
 
You asked the Plan to waive the coinsurance for the C-PAP supplies. You say that you have never had to pay a 
copayment for these supplies before. The Plan denied your request. The Plan says you were charged this 
coinsurance 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 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay 20% coinsurance for the C-PAP supplies. The supplies you received are related to 
your C-PAP machine, which is considered durable medical equipment. 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 continuous positive airway (C-PAP) supplies you received on March 19, 2020.