Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on February 24, 2020 and March 2, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you are going to physical therapy for the same condition. You say that you shouldn't be responsible for a copayment per session. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $15 copayment per therapy, per in-network provider, per visit. You have been asked to pay a $15 copayment for each physical therapy visit. The total amount you owe is $30 ($15/visit x 2 visits = $30). Physical therapy falls within the "Outpatient rehabilitation services" 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 physical therapy provided on February 24, 2020 and March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 drug testing services provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 3, 2020 by an out of network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that
the member's primary care physician did not refer these services.
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 lab work provided on January 3, 2020 by an out of
network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the breast ultrasound provided on March 18, 2020.
You asked the Plan to waive the copayment for the breast ultrasound. You say that this was an annual
mammogram and preventive and therefore, you should not be held financially responsible. The Plan denied
your request. The Plan says that 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms
how much you should expect to pay for diagnostic radiology.
We looked at your contract with the Plan. We did not see where the contract lists when enrollees should expect
to pay a $0 copayment for diagnostic radiology or a $100 copayment for diagnostic radiology. The Plan
contract does not clearly say how much enrollees must pay for diagnostic radiology. This means that the Plan
did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan
has to waive the copayment for the breast ultrasound provided on March 18, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the Colon (74261) provided February 17, 2020. You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $225 copayment for Diagnostic Radiology. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the Diagnostic Radiology 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 Computed Tomography (CT) of the Colon (74261) provided February 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health visit provided on December 23, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for home health visit. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 home health visit provided on December 23, 2019
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on
November 5, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0650) provided to the enrollee on November 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
December 27, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be
responsible for the copayment. You say you were unaware you could deny an ambulance ride. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for each Medicare-covered one-way ambulance trip.
You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls
within the "Ambulance services" 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 ambulance transport provided on December 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral function therapy rendered from February 3, 2020 to
February 28, 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 payment is included in the SNF payment.
The Plan must follow Medicare rules. The rules say that therapy services are included in the SNF global per
diem payment.
We looked at the file and Medicare rules. The services at issue are speech therapy rendered during a SNF stay.
Payment for these services is included in the SNF payment. Therefore, we decided that the Plan does not have
to pay for the oral function therapy rendered from February 3, 2020 to February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 25, 2020.
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 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. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. 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
drug testing services provided on February 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321). You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is medically necessary. The Plan denied your request. The Plan says a trial of Synvisc or Synvisc-One and Euflexxa is required before Hyalgan can be considered. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Hyalgan. Our reviewer says that rules for coverage were not met. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason they would be unsafe or ineffective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 4, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that
the member's primary care physician did not refer these services.
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 lab work provided on September 4, 2019 by an out
of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and diagnostic tests
provided on August 19, 2019.
You asked the Plan to waive the copayment for the office visit and diagnostic tests. You say that the tests were
necessary. You say that you don't think insurance paid enough. The Plan denied your request. The Plan says the
copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25
copayment for each Medicare-covered specialist visit and a $200 copayment for all other diagnostic procedures
and tests.
You have been asked to pay a total of $225 for the office visit and diagnostic tests.
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit
category. The nerve study and needle electromyography fall within the "Outpatient diagnostic tests and
therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the office visit and diagnostic tests provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like to go see this doctor because
you want an alternative to surgery and you have used this doctor before. The Plan denied your request. The
Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an office visit to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Norco.
You asked the Plan to pre-approve Norco. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says Norco is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Norco.
Benefits for Norco 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the transportation provided from December 16,
2019 to December 28, 2019.
You asked the Plan to reimburse you for the routine transportation services. You say that you needed to get to
physical therapy and you have no car. The Plan denied your request. The Plan says you received services from
a provider who is not under contract with the Plan and not certified for Medicare.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation, unlimited trips per calendar year, through their provider.
We looked at your request, the records in the case file, and the rules. You did not use the Plan provider to
access your routine transportation benefit. Based on this information, we decided that the Plan's rules for
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to
reimburse you for the transportation provided from December 16, 2019 to December 28, 2019.
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 requested IRF admission is medically necessary.
The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and
necessary based on Medicare guidelines.
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 the enrollee had a severe motorcycle wreck in March 2020 with multiple injuries and
broken bones. Co-morbid conditions include chronic obstructive pulmonary disease, atrial fibrillation, and
congestive heart failure. Now, the records indicate the enrollee is medically and hemodynamically stable. Pain
is controlled. There is some left lower limb weakness reported. Functionally, the enrollee is
moderate/maximum assist.
Records do not indicate that there are significant, or complex medical/nursing issues that could not be
addressed at a lower level of care. Ongoing pain medication and other medication management, wound care,
and daily therapy can be provided at a lower level of care. In this case, the member is mostly moderate to
maximum assist for functional transfers and activities of daily living and a less intensive, longer duration of
therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in
an IRF level of care.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopath services provided out of network. You asked the Plan to pay for this service. You say that you were told these services would be covered.The Plan denied your request. The Plan says the Plan contract is clear that you are to use in network providers.Medicare rules say that plans can require enrollees to get care from network providers. Medicare does not pay for naturopath services. The contract with the Plan states that all services provided must be in network unless provided as urgent or emergent. This provider in not a network provider. You did not have prior authorization for out of network care. Therefore, we decided that the Plan does not have to pay for naturopath services provided out of network on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the porcelain crown (D2740) for tooth number 23, provided on
January 21, 2020.
You asked the Plan to pay for the porcelain crown. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says that you do not meet criteria for
coverage of the porcelain crown provided for tooth number 23.
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. The Plan covers this porcelain
crown when the services are medically necessary and reasonable.
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 porcelain crown. Our reviewer says that
the porcelain crown provided for tooth number 23 was medically necessary. Our physician reviewer found that
due to the extent of the coronal breakdown of tooth number 23 due to caries, the criteria for coverage of the
porcelain crown (D2740) provided has been met.
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that
the Plan's rules for coverage of the porcelain crown have been met. Therefore, we decided that the Plan has to
pay for the porcelain crown (D2740) for tooth number 23, provided on January 21, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.