Persius/hicric huggingface dataset:
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 December 19, 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 December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture. 
 
You asked the Plan to pre-approve the upper partial denture. You say that you need a new set of dentures that 
can be supported by a different tooth. The Plan denied your request. The Plan says one partial denture is 
allowed every 5 years. 
 
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, you also have a maximum benefit of 1 
complete or partial denture every 5 years. The Plan paid for a partial denture you received on April 20, 2018, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper 
partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dynasplit shoulder brace (CPT Code E1840), for the 
enrollee. 
 
You asked the Plan to pre-approve the shoulder brace. You say that the shoulder brace is medically necessary. 
The Plan denied your request. The Plan says the shoulder brace is not medically 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 shoulder brace. Our physician 
reviewer found the enrollee is noted to have suffered a proximal humerus fracture. Such injuries are usually 
treated conservatively, with a shoulder sling followed by progressive therapy/exercise.  The limited 
documentation provided notes that the fracture is already healed and that the enrollee has been cleared for 
physical therapy (PT). The documentation does not support that the requested Dynasplint is medically 
necessary or reasonable. 
 
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 shoulder brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Dynasplit shoulder brace (CPT Code E1840), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 9, 2020 to 
February 7, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
required no nursing services which would be considered skilled services by Medicare. 
 
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 the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 9, 2020 to February 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 30, 2020 
through May 1, 2020. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not be 
responsible for this bill because if they did the x-ray in the emergency room, and it proved nothing was wrong 
then you could have just left. 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 April 30, 2020 and discharged on May 1, 2020. You were 
asked to pay a $275 copayment for April 30, 2020, day 1 of your inpatient hospital care. You were discharged 
on May 1, 2020 and there was no copayment charge for the day of discharge. Per your contract there is a $275 
copayment per day required for days 1-6. 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 April 30, 2020 through May 1, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the documents submitted state that the enrollee has a 24/7 caregiver in the home. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the records do not 
show that skilled physical or occupational therapy or speech therapy is needed to effectively provide treatment, 
care, and/or services in order to improve your level of function, or to establish/perform a maintenance program 
to maintain your level of function and/or prevent deterioration. Your functional level does not require ongoing 
skilled therapy. You are non-ambulatory and uses a Hoyer lift for transfers. Your swallowing function was 
within normal limits and he had mild impairments in cognitive ability. As you do not require ongoing skilled 
therapy services, you do not meet the definition of ongoing remaining 10 home health aide services per Section 
50.2 and the request for the remaining home health aide services are not reasonable and necessary to the 
treatment of your illness or injury by the skilled professional staff. 
 
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 pre-approve home health services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT, maxillofacial area; without contrast 
material (70486) provided on October 7, 2019. 
 
You asked the Plan to waive the copayment for the CT scan. You say that the doctor failed to get a prior 
authorization and it is not your fault that they did not get it. The Plan denied your request. The Plan says the 
claim was 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 had a CT scan performed on October 7, 2019 The Medicare-allowed amount 
for the CT scan is less than the set $270 copayment; therefore, you have been asked to pay the lesser amount of 
$129.51 for the CT scan. Your EOC states that enrollees must pay a $270 copayment for all other diagnostic 
procedures and tests. 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 CT, maxillofacial area; 
without contrast material (70486) provided on October 7, 2019.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 76705) provided on October 6, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 76705 is "Ultrasound, abdominal, real time with image 
documentation; limited (e.g., single organ, quadrant, follow-up)". 
 
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 CPT code 76705 is not supported by the records provided. Our physician reviewer found that the 
documentation did not include an "Ultrasound of abdomen, real time with image documentation". Also, images 
were not included with documentation reviewed. 
 
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 (CPT 76705) provided on October 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the compression stockings provided on 
April 10, 2020 by an in-network provider. 
 
You asked the Plan to waive the copayment for the compression stockings. You say that you returned the 
support hose to the provider because they were too small and too expensive. The Plan denied your request. The 
Plan says the claim was processed accordingly with your 2020 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received the compression stockings provided on April 10, 2020 by an in-
network provider. The Medicare-allowed amount for the DME is less than the set $20 copayment; therefore, 
you have been asked to pay the lesser amount of $8.90 for the stockings. 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 compression stockings provided on April 10, 2020 by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physician services and outpatient visits 
provided on February 12, 2019 to December 19, 2019. 
 
You asked the Plan to waive the copayment for physician services and outpatient visits. You say that you do 
not agree with these charges. The Plan denied your request. The Plan says the correct cost-sharing amounts 
have been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $185 
deductible and a $20 copayment for physician/practitioner services/specialist.  
 
You have been asked to pay a total of $172.37 for physician services and outpatient visits. The correct 
deductible and copayments have been applied. Physician services and outpatient visits falls within the 
physician/practitioner services/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 physician services and outpatient visits provided on February 12, 2019 to December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit to check the battery of a power scooter. 
 
You asked the Plan to pre-approve the office visit. You say that the enrollee has stenosis of his spine and 
cannot walk. His legs and knees atrophied which are bone on bone and extremely painful. The battery of your 
current scooter is not charging. The Plan denied your request. The Plan says the records do not support that the 
enrollee meets the criteria for a power scooter therefore the office visit to check the battery of the power 
scooter and is not covered. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 office visit. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation indicates the enrollee has a mobility deficit. The enrollee is able to perform 
MRADLs in the home and ambulate in the home with a single point cane.   The PCP dated 05/12/2020 showed 
that he uses a single point cane for ambulation, lives in a single level home, does not drive, goes independently 
to the toilet, and able to feed, bathe, dress and transfer himself alone. There is no objective evaluation of the 
home indicating that the enrollee can safely navigate the PMD in the home or that the mobility deficit is unable 
to be helped by a manual wheelchair, cane, or walker. The medical records provided do not show that the 
enrollee meet the requirements listed in the LCD for Medicare coverage of the scooter therefore the services 
related to this scooter are 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 the office visit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the office visit to check the battery of a power scooter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan of 
the abdomen (74160) provided on October 25, 2019. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance 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 0% 
coinsurance for mammography and ultrasounds and a 20% coinsurance for all other diagnostic and nuclear 
medicine radiological services.  
 
You have been asked to pay a $54.09 coinsurance ($270.44 allowed amount x 20% coinsurance) for the CT 
scan 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 coinsurance for the computed tomography (CT) scan of the 
abdomen (74160) provided on October 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you called an ambulance 
because you were instructed to come alone to the emergency room. The Plan denied your request. The Plan 
says you were charged this cost sharing 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 $300 
copayment for each ambulance trip. You had one ambulance trip. The Plan charged you $300 for these 
services. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for the ambulance services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from January 17, 2020 
to February 3, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the services 
the enrollee received during this time are considered custodial. The Plan also says that the enrollee did not need 
skilled medical care or skilled nursing care. 
 
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 the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 17, 2020 to February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the eyewear purchased on March 2, 2020 from a non-participating provider.
You asked the Plan to reimburse for the eyewear. You say that you exhausted your options prior to presenting for services with this non-participating provider. The Plan denied your request. The Plan says prior to receiving the services you called the Plan and were advised this provider was not a participating plan provider and the Plan gave you several in-network plan providers at this time.
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 reimburse 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 reimburse for these items/services. Therefore, we decided that the Plan does not have to reimburse for the eyewear purchased on March 2, 2020 from a non-participating provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the emergency room visit provided from 
July 12, 2019 to July 13, 2019. 
 
You asked the Plan to reduce the copayment for the emergency room visit. You say that you were incorrectly 
billed $200 for the emergency room visit and the providers you saw while at the emergency room. You say you 
should be charged a $90 copayment. The Plan denied your request. The Plan says the claim was reprocessed 
from a $200 copayment to a $90 copayment for the emergency room  
 
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 reduce the copayment for the 
emergency room visit provided from July 12, 2019 to July 13, 2019.