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

 
We decided that the Plan does not have to pay for out of network chiropractic services provided on March 12, 
2020. 
 
You asked the Plan to pay for these services. You say that this service should be covered by the Plan. The Plan 
denied your request. The Plan says those services not related to manual manipulation of the spine are not 
covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not 
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for out of network 
chiropractic services provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 16, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 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 May 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the ophthalmology services. You say that you would like reconsideration 
because you would like to see this provider to improve your vision if possible. The Plan denied your request. 
The Plan says it is not medically reasonable or necessary to refer the member to a non-Plan ophthalmologist for 
treatment when services are available from network providers. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided April 3, 
2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that the copayment 
should be waived. 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 $90 
copayment for Emergency Care.  
 
You have been asked to pay a $90 copayment for the emergency room services. the emergency room services 
fall within the Emergency Care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
emergency room services provided April 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two office visits to be provided by the requested 
physician. 
 
You asked the Plan to pre-approve three office visits for the physician's service. You say that you were in an 
auto accident and required neurosurgery on August 7, 2019 with this physician. You say you have since been 
followed with this physician for subarachnoid hemorrhages and you need to continue follow up care with this 
physician. The Plan denied your request. The Plan says only a single transitional visit is covered rather than 
three visits. After that visit, the member will need to migrate to an in-network Medicare-contracted provider in 
order to be covered for the visits. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve two office 
visits to be provided by the requested physician.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) and 
echocardiogram provided on March 17, 2020. 
 
You asked the Plan to waive the copayment for EKG and echocardiogram. You say that these services have 
always been covered previously. The Plan denied your request. The Plan says the copayment amount you are 
being charged is correct. The Plan also says that they have waived the copayment for this office visit, therefore 
you are only responsible for the $75 diagnostic testing copayment. 
 
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 $75 
copayment for EKG and echocardiogram.  
 
You have been asked to pay $75 copayment for EKG and echocardiogram. EKG and echocardiogram fall 
within the Outpatient Diagnostic Testing 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 an electrocardiogram (EKG) and echocardiogram provided on March 
17, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services providedon March 29, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell at home and may have broken your 
arm. You say the ambulance did not want to transport you because of Covid. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 29, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services providedon March 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4342) of the 
upper right quadrant. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing of one to three teeth per quadrant. 
The Plan denied your request. The Plan says this service is not covered under the enrollee's benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
periodontal scaling and root planing (D4342) of the upper right quadrant.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on March 19, 
2020. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that previous visits with identical 
services have had a copayment of $50, and you should not have to pay this surprise charge. The Plan denied 
your request. The Plan says the copayment amount you are being charged is correct. 
 
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 $450 
copayment for in-network outpatient surgery at an outpatient hospital.  
 
You have been asked to pay the allowed amount of $110, which is less than the $450 copayment for outpatient 
surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital 
Outpatient Facilities and Ambulatory Surgical Centers 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 outpatient surgery provided on March 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on May 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
were not supported. 
 
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 May 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthosis (L1851) suspension sleeve (L2397) and 
lumbar-sacral orthosis (L0650) provided February 24, 2020. 
 
You asked the Plan to pay for the orthoses. You say that please see the attached documentation to prove 
medical necessity. The Plan denied your request. The Plan says there is no actual physical exam, all 
information was provided over the phone, the documentation does not identify the enrollee's originating site at 
the time of the telehealth visit, there are no actual treatment records provided to substantiate the enrollee's 
orally reported medical history, there is no evidence of an established relationship between the enrollee and the 
ordering physician, there was no claims submitted for an evaluation and management service and there is no 
evidence of a prior telehealth service with the ordering physician as required per CMS guidelines. 
 
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 knee orthosis (L1851) 
suspension sleeve (L2397) and lumbar-sacral orthosis (L0650) provided February 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing (G0299x18) and physical therapy 
(G015113) home visits provided June 12, 2019 to July 30, 2019. 
 
You asked the Plan to pay for the skilled nursing and physical therapy home visits. You say that you are 
needing the status of payment for the claim. The Plan denied your request. The Plan says this claim is unable to 
be reprocessed due to a billing error. Payment will be reconsidered when a corrected claim is provided. 
 
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 claim cannot be processed due to Pricer Return Code 38 edit. The claim. did not include any of 
the following HCPCS codes: Q5001, Q5002, or Q5009 which is necessary to price the claim. Therefore, a 
corrected claim must be submitted. Based on this information, we decided that Medicare rules for coverage of 
the skilled nursing and physical therapy home visits have not been met. Therefore, we decided that the Plan 
does not have to pay for the skilled nursing (G0299x18) and physical therapy (G015113) home visits provided 
June 12, 2019 to July 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for outpatient rehabilitation services provided 
on November 19, 2019. 
 
You asked the Plan to waive the cost-sharing for outpatient rehab. You say that you were told this provider was 
in-network. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 
correct. 
 
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 $500 
deductible and 30% coinsurance for out-of-network outpatient rehab. At the time this claim was processed, 
$93.65 of the $500 out-of-network deductible had been met. The allowed amount of the claim is $511.25, 
resulting in a deductible amount of $406.35 which meets the $500 total out-of-network deductible for 2019. 
The remaining allowed amount of the claim is $104.90, resulting in a coinsurance amount of $31.47. Your total 
cost-sharing obligation is therefore $437.82. 
 
You have been asked to pay $500 deductible and 30% coinsurance for out-of-network outpatient rehab. 
Outpatient rehab 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 cost-sharing for outpatient rehabilitation services provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the copayment and coinsurance for chemotherapy provided on February 
20, 2020. 
 
You asked the Plan to waive the copayment and coinsurance for chemotherapy. You say that you did not 
receive services on that date of service and disagree with the charges. The Plan denied your request. The Plan 
says that the claims were processed correctly and you are being charged the correct amount. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan provided medical records for the wrong date of service. Without 
medical records for February 20, 2020 we cannot confirm if services were rendered. Therefore, we decided that 
the Plan has to waive the copayment and coinsurance for chemotherapy provided on February 20, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Rituximab infusion provided on 
November 21, 2019. 
 
You asked the Plan to waive the cost share for the service provided. You say that you are on a fixed income. 
The Plan denied your request. The Plan says the coinsurance for the infusion was applied appropriately. 
 
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 10% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay a 10% coinsurance for the service provided. The service falls 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 cost share for the 
Rituximab infusion provided on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on July 22, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 
were not supported. 
 
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 July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 26, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the nail debridement (11056 and 11721) provided on June 26, 2019.. You say 
that you would like reconsideration because the member presented with incorrect information. The Plan denied 
your request. The Plan says utilization of network providers is required when possible and 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 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 medical services provided on June 26, 2019 by 
an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room visit provided on 
February 24, 2020. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that the provider should not be 
paid any amount because of the quality of care you experienced at this visit. The Plan denied your request. The 
Plan says the copayment amount you are being charged is correct. 
 
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 $90 
copayment for emergency room visit.  
 
You have been asked to pay $90 copayment for emergency room visit. emergency room visit falls within the 
Emergency Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
visit provided on February 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient radiology services provided on January 22, 2020. 
 
You asked the Plan to pay for the outpatient radiology services. The Plan denied your request. The Plan says 
the enrollee must receive care from in-network providers with the exception of emergency or urgent care, 
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network 
provider, which requires prior authorization from the plan. 
 
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 outpatient radiology services provided on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 24, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that the test evaluates the need for a prostate biopsy. 
The Plan denied your request. The Plan says prior authorization was not 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 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 January 24, 2020 by an out of 
network (OON) provider.